Men & Emotions Workshop 2022 - Restoration Counseling NW

Men & Emotions: Information Form

Your Name *

First

Last

Cell Phone *

Age *

Email *

I understand that 6 months of sobriety (from any addiction) is strongly suggested before attending this group: *

I am have not experienced relapse in the last 6 months.

I understand that whatever I share or others share during the group is confidential and is not to be shared outside of the group: *

I agree to confidentiality

I understand that the fee covers six weeks of group and no part will be refunded if I decide to stop attending. The book, "Why Emotions Matter" is required and I will purchase it. *

I am all in!

My desired goals for this group: *

What are you hoping to get out of this?

Are you currently working with a counselor? *

Counselor Name

Who referred you to the group / How did you hear about this? *

May I thank them for the referral?

Message

Restoration Counseling NW
314 W 15th St Suite 200, Vancouver, WA 98660

Men & Emotions: Information Form

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