Name
*
First Name
Last Name
Best email for correspondence during the program
*
Phone
*
Country
(###)
###
####
Emergency Contact Name
*
We'll only use this contact in the case of a medical or mental health emergency.
First Name
Last Name
Emegency Contact Phone Number
*
(###)
###
####
What diocese or college do you belong to? (If not applicable, then put your city and state.)
*
Have you discussed your family wounds with a counselor, priest, or a trusted friend?
*
We believe our programs are a great complement to counseling, spiritual direction, and/or ongoing conversation with trusted friends. Knowing this information helps us to best serve you during the program.
Do you feel emotionally and psychologically capable at this time to attend an event where strong emotional content about family life will be discussed, shared, and processed?
*
If you are seeing a counselor or psychologist, then please consult first with him or her about whether he or she believes it is a good time for you to attend a program like this one.
When did your parents divorce or separate? (Don't know? Then put "unsure." And put n/a if not applicable.)
*
How old were you?
How did you hear about the program?
*
Life-Giving Wounds website
Life-Giving Wounds book
Online search
Facebook or Instagram
Beth Sri's talk at SEEK
Referred by a friend, LGW alumni, or LGW chapter
Referred by one of our speakers
Podcast
A previous Life-Giving Wounds Event
Other
If you answered "Other" above, please let us know how you heard about the program:
Are any family members, a significant other, or friends attending this event with you? If yes, list their name(s) here and let us know if you'd like to be in the same small group as them or not.
Would you like to opt out of small groups? (leave unchecked if you plan to attend the small groups)
Is there anything else you feel would be helpful to share with the leadership team at this time?
