Redirect Your Life for Singles

Redirect Your Life Singles Form

Tuition: Total cost of course $495.00 this requires a $100 Deposit. (Balance due before the weekend.)

Required *

Name

Address

City

State

Zip Code

Phone Number

Your Goals for the Singles Adventure Course

What type of romantic relationship would you like?

What would you like to gain from attending the Singles Adventure?

Additional Information

Describe the relationship between your parents.

How did you find out about sex and what are your current beliefs about sex?

What was the duration of your last 4 relationships? Please List as 1.,2.,3.,4.

What is your greatest challenge in seeking, finding and maintaining a relationship?

In your last 2 relationships how did you meet? How did the relationship end?

Met

Ended

Met

Ended

Print or type four of your early recollections. It does not matter how old you were as long as the memory is the earliest experience you remember that meets the stated requirement of the recollection. An early recollection describes a specific one-day event. Examples:

Example #1 age 7. One day I was riding my bike on the street and my brother yelled at me to stop. I felt scared.

Example #1 qualifies as an Early Recollection because it describes an actual event.

Example #2 “My brother and I used to ride our bikes on the street.”

Example #2 does NOT qualify as an Early Recollection because it describes something that happened often and does not give the details of specifically what occurred on one day. It is also missing the age and how he felt.

Early Recollection 1 Age & Incident

I Felt

Early Recollection 2 Age & Incident

I Felt

Early Recollection 3 Age & Incident

I Felt

Early Recollection 4 Age & Incident

I Felt

Vision Information

Describe your ideal relationship

List the past hurts you have from previous relationships, including the relationship with your parents.

Payment Method * Check Credit Card

Credit Card Type Visa MC Discover Amex

Credit Card Number

Expiration Date

CVV Number

Billing Address *

I am aware that breaking the agreement would greatly minimize the value I would gain from the course, and therefore, I will be responsible for overcoming any circumstances which would prevent me from keeping this agreement.

I agree to attend, in their entirety, all sessions of the course.

I agree to be on time for each session.

I agree to return the Student Information Sheet and this signed Enrollment Agreement Form within 5 days.

I agree not to take any non-prescription drugs or alcohol within 24 hours of any session.

As a participant of this course, I agree to respect the confidentiality of all participants and their remarks.

Informed Consent Agreement

I understand that this course is educational and NOT psychotherapy or a substitute for psychotherapy.

I have read and understand this entire agreement and agree to these terms and conditions above.

I have read and understand this entire agreement and agree to these terms and conditions above. *

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