Register WKSP Qct 22 — Steven W Shields

Registration Form

October 12th - 17th, 2022 Healing Trauma Workshop

Note: If you are not currently a client of Steven Shields or James Willhite you will need to come in for a single introductory session prior to the workshop. You will not be charged for this session as it is included in the workshop.

Name

First Name

Last Name

Phone

(###)

###

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Preferred Method of Contact

Room Preference

Adventure Interests

UTV's

Paintball

Fishing

Hiking

Skeet Shooting

Food allergies or preferences

Anything your allergic too? Also what type of food and snacks do you prefer?

Are you currently seeing a therapist or counselor?

Yes

If yes, who is your current counselor and how long have you been in treatment with them?

We will not contact your current counselor without your written consent. However, we do like to work with them for preparation for the workshop and aftercare and will potentially ask your permission to contact them.

Message

Anything additional you'd like to let me know about you are specific questions about the workshop you'd like answered.