Name *

First Name

Last Name

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

Emergency contact phone number *

(###)

###

####

Have you discussed your family wounds with a counselor, priest, or a trusted friend? *

We believe our programs and events 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 book club.

Yes

No

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 an event like this one.

Yes