Nurtureways · Listening Mothers Registration

Contact Information

Name

*

First Name

Last Name

Partner's Name (if applicable)

First Name

Last Name

Relationship Status

*

Email

*

Verify Email

*

Phone

*

To be used for pre-group contact call

Ok to receive text communications at this number?

Yes

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Child's Information

Baby's name

*

Baby's Date of Birth

*

Baby's Sex at Birth

*

Additional information about your baby

Please feel free to tell us any additional information you would like to share about your baby

Ages of other children in the household (if applicable)

Mother/Baby picture

*

Please upload a selfie picture of you and your baby to capture this moment in time :) We will take another selfie towards the end of our group time together as well

Class Registration

How did you hear about Listening Mothers?

Which Group are you Registering for

*

Tuesdays 9:30-11am PST, October 4th-November 8th

Mondays 12:00-1:30pm PST, November 7th-December 12th

Scholarship Code

Registration Type

*

$195 - Individual Parent

What are you hoping for from participation in this group?

*

Legal Disclaimer:
Withdrawal from a Group: Due to limited class space and payment holding your spot, we cannot issue a refund if you decide to withdraw from a group after the point in time that is 7 days prior to the group starting.

Employee Assistance Program Benefits: Your company or your spouse’s company may provide payment to Listening Mothers through an EAP. If your company wants to talk with Listening Mothers about creating an Employee Benefit, please have them contact us. Withdrawal rules apply as above.

Consent: Participation in this group is voluntary and not a substitute for mental health treatment. In the case of an emergency, contact 911. Virtual groups may utilize non-HIPAA compliant platform(s) which include potential risks, included interruptions, unauthorized access, and technical difficulties.

Confidentiality: No information about you is released from Nurtureways to anyone without your written permission, except as required by law or court order. We are required by law to report suspected child abuse (regardless of when it occurred), elder abuse and clear, concrete evidence of planned acts of violence.

Registration Agreement

*

I understand and accept these terms of registration