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Circle of Security Interest Form
Nurture Collective's Circle of Security Parenting Course
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* Indicates required question
Email address
*
Your answer
First and Last Name
*
Your answer
Child's First and Last Name
*
Your answer
I am interested in participating in the 10-week Circle of Security Parenting Course.
*
Yes
No
How did you hear about this program?
Instagram
Nurture Collective's website
Service (OT, PT, ST) Provider
Other:
Clear selection
Are you able to pay the $30/session ($300/program) or will you need financial assistance?
Yes, I can pay the full $300
Yes, I can pay in $30 increments for 10 weeks
No, I will need financial assistance
Clear selection
I have reliable access to a virtual mode of communication (i.e. phone, computer, tablet with video).
*
Yes
No
This course requires self-reflection regarding previous childhood experiences. Do you have any traumatic childhood experiences that may make it difficult to participate in the course?
*
Yes
No
Days and times of availability (i.e. Mondays 5pm-6pm, Wednesdays 1pm-2pm)
*
Your answer
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