Making Sense of Your Worth and Parenting for Positive Self Worth - Canadian County Application

PPSW Waitlist – Yukon/Canadian County

Thank you for applying to be a part of the 16 week Making Sense of Your Worth and Parenting for Positive Self-Worth Program. We are looking forward to meeting you and helping you break free from any trauma that may have a stronghold in your life. It is our belief that you will find deep healing in this program, not only for you but for your children. Once you fill out the application below, you will be added to our waitlist and should receive a confirmation email within 24 hours. Way to be brave and sign up

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
Phone*
May we send a text or leave a message on voice mail?*
- Yes
- No
Email
How did you hear about this program?*
Snacks may be provided. Do you have any food allergies?
We will do our best to accommodate your needs!
Are you receiving counseling or support through any other programs or agencies? If so, where?
List*
First Name Last Name Age Does this child currently live with you?
Please check one or multiple options:*
- I can attend classes during the weekday anytime 8:00am-5:00pm for a 2-hour session.
- I can attend attend classes during the evening 6:00pm-8:00pm.

First Name	Last Name	Age	Does this child currently live with you?

Making Sense of Your Worth and Parenting for Positive Self Worth – Canadian County Application

PPSW Waitlist – Yukon/Canadian County