Redirect Your Life for Teens

Teens Name *

Date of Birth *

Address *

City *

State *

Zip Code *

Phone Number *

Date of Course *

Location *

Enrolled By *

TShirt Size

Parent Course Information Sheet

Parents' or Guardians' Names *

List 3 things I LOVE about my teen:

What is the greatest challenge facing your teen?

What is the one thing you want for your teen as a result of taking the course?

How does your teen get along with siblings and friends?

Is there anything you want us to know that might help your teen get the most from being at the Teen course?

Does your teen have any physical limitations or medical conditions? yes no

If Yes, Please Specify

Is your teen on medication? yes no

If Yes, Please List

Will your teen need to take medication over the weekend? yes no

Give name, dosage and number of times a day taken

Emergency phone number to reach you during the weekend *

Additional Comments

I give my permission for my teen to participate fully in the weekend. * yes

The following questionnaire is to help you achieve the most results from your weekend. This information will allow the instructors to assist you in reaching your goals. By clarifying your goals in your own mind, you will be better prepared to ensure a more successful weekend. We look forward to assisting you with making the weekend a valuable and rewarding experience.

FAMILY INFORMATION
List the 1.) name, 2.) age, 3.) Occupation, 4.) Personality Trait, 5.) Death
Do this for each member of your family below. Include step family info.

Name of Father / Male Guardian *

Name of Mother / Female Guardian *

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Sibling 5

EARLY RECOLLECTIONS

Print or type two (2) early recollections. An early recollection is a memory of a SPECIFIC INCIDENT when you were a child or baby.

• Example of an early recollection

Age 4-5: One day my parents brought home a new baby. I felt left out and lonely.

Notice that the above recollection describes a specific incident. It is not a generalized report.

• The following is NOT an early recollection.

When I was a kid I always used to ride a tricycle and fight with my brother.

It doesn’t matter if the experiences you recall are positive or negative. It also does not matter how far back you can remember as long as they are your earliest memories.

Write two recollections in the spaces below. Give your approximate age and describe how you felt.

Early Recollection 1 Age & Incident

I Felt

Early Recollection 2 Age & Incident

I Felt

Who do you trust the most and why?

Where do you go to feel safe?

Have you ever been exposed to any form of substance abuse?

Have you ever experience any sexual, emotional, mental, physical or religious abuse? Describe:

What gets you the most discouraged?

What has you feeling the most encouraged?

How do you express your feelings?

What are the two most significant events in your life?

Tuition:Total cost of course $495.00 this requires a deposit of $100.00

Payment Method * Check Credit Card

Credit Card Type Visa MC Discover Amex

Credit Card Number

Expiration Date

CVV Number

Billing Address

INFORMED CONSENT AGREEMENT

• I understand that this course is educational and NOT psychotherapy or a substitute for psychotherapy.
• I understand that in addition to the benefits, there is always the risk of emotional and/or medical contingencies in such a group experience. I assume the risk, by this consent, of accident or injury to my teen during this course, or inflicted by my teen during the course, and hereby release the instructors and M/C Insights, Inc. from any liability thereof.
• I take responsibility for consulting with a medical doctor for my teen prior to participating in the course concerning any known or potential emotional or physical conditions that they have or may have, for the purpose of getting permission to participate. I assume the risk, by this consent, of any illness during the course, and hereby release the instructors and M/C Insights, Inc. for any liability thereof.
• I hereby authorize the instructors to take any reasonable steps on my teen’s behalf in the case of an accident, injury or illness, including but not limited to, first aid, doctor, nurse and /or ambulance services, etc. I agree to be liable for the cost of any such actions taken on my teen’s behalf and hereby release the instructors and M/C Insights, Inc. for any liability thereof.
• If my teen has had serious emotional problems or has been hospitalized for emotional problems or my teen is currently under the care of a psychologist or psychiatrist, I understand that it is required that my teen attends the program only with the written permission of his/her therapist.

REFUND POLICY

After the course, if you are dissatisfied, your tuition will be refunded provided all of the following conditions have been met:
• Your teen has been in attendance the full time for each of the sessions of the course.
• Your teen has participated in all the exercises of the course.
• Your teen has met with the instructors.
• You or your teen has submitted a request for a refund, stating the reasons for your dissatisfaction within seven days of the last session of your course.

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

Please type the following: