Partner 1 *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Partner 2 *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How connected are you and your partner? *

We are solid, we just want to feel closer

Occasional distress, strong commitment

We’ve been struggling a lot

High distress, we are in trouble

Are you currently in therapy? *

Yes, couples therapy

Yes, Partner 1 attends individual therapy

Yes, Partner 2 attends individual therapy

No

Terms of Agreement and Cancellation Policy *

Terms of Agreement This program is not appropriate when there is an explicit and obvious lack of commitment to the growth of the relationship by either partner, when there is physical or emotional abuse in the relationship, or when there is a mental illness or addiction in either partner that would preclude productive engagement in the workshop experience. If you or your partner are experiencing significant relationship distress, serious depression or mental health problems, we urge you to seek professional treatment immediately and consider attending this workshop only under the direction of your physician or licensed mental health professional. ​The Hold Me Tight workshop is an educational resource for couples interested in enhancing the quality of their relationship. This program is not couples therapy and is not intended to be a substitute for couples therapy with a trained professional therapist. Due to the group format of the workshop, the confidentiality of workshop participants cannot be guaranteed. However, group facilitators will not release any information regarding participation in the group without a signed consent from both partners. Cancellation Policy Your registration fee is non-refundable, but transferable. Once registered, if unforeseen circumstances prevent you from attending the Hold Me Tight® Workshop you registered for, you are welcome to attend another workshop within that calendar year instead.

By checking this box you agree to the Terms of Agreement and Cancellation Policy outlined above