Love, Connection + the Brain 10-Week Virtual Group

Full Name (Primary Contact): *

First Name

Last Name

Phone Number (Optional)

(###)

###

####

Preferred Method of Communication: *

(email, text, video phone, other)

Email

Text

VP

Other

What time zone are you in? *

Eastern (EST)

Central (CST)

Mountain (MST)

Pacific (PST)

Alaska/Hawaii

Other:

Are Tuesday or Thursday mornings (EST) accessible for you to join live sessions on Zoom? *

Yes

No

I need an alternative

CheckboxIs Zoom (with captions and follow-up notes) accessible to you? *

Yes

No

I’m not sure — please follow up with me

Please confirm your understanding of the following: *

✅ I understand recordings will not be provided due to the personal and confidential nature of the group. ✅ I understand slides, notes, and resources will be shared whether I attend live or not. ✅ I understand this group is not a replacement for therapy. ✅ I understand this class is offered with equity in mind and that a sliding scale is available. I confirm:

Yes

No

Would you like to be paired with a study buddy or another parent for mutual support?

Yes

No

Maybe / Undecided

Which cohort/group are you interested in? *

Summer (starts June)

Fall (starts October)

Either

This class is offered on a sliding scale. How do you plan to pay? *

I can pay $25–$55 per session

I will need a free or reduced-rate seat

I’d like to discuss privately