RLC Nurturing Motherhood Workshop Registration
Demographic Information and Consent Below

For questions about this form or the class, please email office@resilientlifeutah.com or give us a call at 
(385) 316-7127

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First and Last Name *
Email Address *
Phone Number *
Date of Birth *
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What interested you about the Nurturing Motherhood Workshop?
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How did you hear about this Workshop?  *
What do you hope to get out of this class?
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Registration preference 
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Are you a previous or current client of Resilient Life Counseling?
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Description: Resilient Life Counseling is hosting an online Nurturing Motherhood Workshop to help moms thrive and find joy in being a mother! Topics include: Navigating Stress and Anxiety, Mastering Your Mood, Intentional Self-Care, and Creating the Life You Want. 

PLEASE NOTE that this an educational class, and it is not therapy. 

Informed Consent for Participation in the Nurturing Motherhood Workshop: 
I will be a participant in this class and will not share any private information while in the class. This will help to ensure privacy and confidentially for the each participant while participating in the class.

Confidentiality:
The class content and all relevant materials and discussions will be held confidential unless the participant requests in writing to have all or portions of such content released to a specifically named person/persons. Some limitations may apply. 

Occasionally, we may need to consult with other professionals in their areas of expertise in order to provide the best support for participants. Information about participants may be shared in this context without using participant's name. 


BY ENTERING MY NAME BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS FORM
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