Register for a group or workshop

In order for us to best understand how to support you in our groups and workshops, it’s important that we gather some information about you, your estrangement and your wellbeing. This should take no more than 5-10 minutes to fill in. Please be aware we won’t be able to respond to your personal circumstances at this stage, but this form will allow you to access our groups and workshops, where you can find support with your situation. If you struggle to submit this form, please click here

Please fill in the form below

First Name

Last Name

DOB

Phone

Mobile

Gender

Where
did you hear about us?

Address

Street and House no

Town

County

Postcode

Emergency Contact

Emergency Contact Phone

Who are you experiencing estrangement from?

How long have you been experiencing estrangement?

Briefly tell us about your estrangement in your own words… (max 100 words)

Please describe your thoughts on reconciliation

Are you currently seeing a counsellor, therapist or psychologist?

GP’s name and address

Have you ever been diagnosed with any of the following?

Have you been prescribed medication in relation to this diagnosis?

Name of medication

Tell us about your wellbeing strategies. How do you look after yourself?

Tell us about your support network

Please set up three goals you would like to achieve

Goal 1

Goal 2

Goal 3

Need assistance with this form?