Booking Form | Peer Support Group

Thank you for taking the time to complete this as honestly and fully as you can. Your details will be held in confidence and will not be shared with any third parties. If you have any questions or difficulty completing this form, Please call Diane on +61 417 683 006.

Which location is this workshop being held? *

First Name *

Date Of Birth *

Day *

Month *

Year *

Phone Number *

Email Address *

Street Address *

Please note this group is only for people who have already done Family Constellations. What has been your experience so far of Family Constellations? Tick all that apply.* *

In a Private Session/sIn a Workshop/s

Anything you’d like me to know including, when, where, with whom and Outcomes? (Optional):

Health

Are you currently seeking Counselling, Coaching or Therapy from any other source? *

If "Yes", please provide details:

Do you have any chronic/recurrent illness &/pain or health concerns? *

If "Yes", please provide details:

Have you ever or are you now experiencing sleeplessness, anxiety or depression, or a nervous condition? *

If "Yes", please provide details:

Are you taking any medication for a physical or mental health issue? *

If "Yes", please provide details:

And finally, Please add anything else you would like me to know at this point. (Optional)

Cancellation Policy

Total Tuition for 5 x Bi-monthly days = $825.
A non-refundable deposit of $165 will be required to secure your place, with either the remainder of the full fee or the first instalment of $275 due prior to the first session.
The remaining 2 x $275 instalments will be due prior to the 2nd & 3rd sessions.
You will need to attend all sessions and in the event that you cannot make a session, there will be no refunds or transfers.
In the unlikely event that the Course is cancelled, you will be refunded in full or your tuition may be transferred to the next available Course, Workshop/s &/or private session/s if you choose.

Agreements | Please Read Carefully

Ticking the boxes indicates your acceptance of these Agreements.

I acknowledge that I am at least 18 years old.
I have read and accepted the Cancellation Policy.
I agree to respect the confidentiality of all participants in the Workshop.
I understand that everyone in the group is an integral part of the Course and agree to be on time and attend for the full duration of the 5 days of the Course, including lunchtime.
I understand that, while every effort will be made to ensure the comfort and safety of all participants, I may experience strong emotions participating in the group and am willing to be responsible for my well-being and to ask for help and support during and/or after the Course if necessary.
I understand that this may be part of my overall healing process and take full responsibility for doing any follow-up work with Diane &/or my existing 'Counsellor' to integrate this and receive the full benefits available to me.
I understand that as a part of my Course commitment I will be receiving course information and support via email and I will open and read them!

Accept all terms & conditions

Payment

Please indicate if you prefer to pay via Direct Credit to my account or - only if using a credit card - via PayPal, and I will forward you an invoice for payment. Please note payment is due on receipt of the invoice for your registration to be complete.

I wish to pay by: *

Booking Form | Peer Support Group

Peer Support Group – Systemic Family Constellations

How did you find out about the Workshop? *

Please note this group is only for people who have already done Family Constellations. What has been your experience so far of Family Constellations? Tick all that apply.* *

Health

Cancellation Policy

Agreements | Please Read Carefully

Payment