Course/Workshop Registration

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Important!

If you are a new client or have not filled out the Family Place Intake Form, please complete it before proceeding with additional form submissions. This information is essential for us to provide the best service possible.

Course/Workshop Registration

Please select the course you would like to register for and provide some basic contact information.

Course^*

First Name^*

Last Name^*

Date of Birth^*

Phone Number^*

Email Address^*

Demographic Information

The following demographic information is collected for reporting purposes only. Your responses will remain confidential.

Has anyone in your household been, or currently is, a refugee?

Prefer Not To Answer

Yes

Are you Spanish speaking or do you serve Spanish speakers?

Prefer Not To Answer

Yes

Are you a mental health professional pr do you work in a related field?

Prefer Not To Answer

Yes

Do you know someone suffering/recovering from opioid addiction or are you suffering/recovering from opioid addition?

Prefer Not To Answer

Yes

Has anyone in your household been in foster care?

Prefer Not To Answer

Yes

Has anyone in your home experienced depression or other mental illness?

Prefer Not To Answer

Yes

Has anyone in your home had suicidal thoughts or attempted suicide?

Prefer Not To Answer

Yes

Does anyone in your home have a criminal history?

Prefer Not To Answer

Yes