LEVEL 1: PARENTAL ALIENATION SUPPORT GROUP REGISTRATION

THANK YOU for registering for our Support Group.
We are so happy you are here!

REGISTRATION

If you have any questions about this form or registration please email Mark Roseman prior to your first meeting with any questions.

Full Name

Phone

Residence (street)

City

State

Zip

DOB

Marital Status

Vocation/Profession

# of Years

Number of Children

Ages, Gender

1. Do you feel rejected by your children? Y/N; if yes, what are those signs of rejection?

2. Do you believe your children have been brainwashed against you? Y/N; if yes, by whom? Why?

3. How long ago did you notice the change in your children’s behavior towards you?

4. What is the ideal relationship you would like to build with your children?

5. What are you struggling with the most right now? (Personal healing, relationship health, etc.)

6. What are you doing to help yourself heal? How much are you willing to invest to solve this?

7. Are you making your overall health a priority each week? Mental, physical, emotional, and spiritual?

8. What would you like the most to accomplish by participating in this support group?

Please CLICK HERE if you agree to these terms:
The support group is a forum for thoughtful commentary and civil dialogue intended to enlighten your fellow parents with additional insight, tips, or counterpoints. Importantly, it is a facilitated peer group to help you achieve your individual objectives for the understanding of the changing family condition and personal growth.
As a group, we are each committed and must commit to a standard of behavior that is acceptable to all and non-threatening. The goals of your facilitator is to help you achieve the most fundamental benefits, acceptance and community. With these goals in mind, here then is a list for you to also acknowledge which we believe are to be avoided.
Off-topic comments. Comments need to tie-in to health and healing on our journey, or to the “syndrome” of PA, so please keep them relevant. We have to be especially strict in regard to hot-button and sensitive topics.
Hate speech, offensive or obscene language.
Personal attacks or name calling towards any other person, or groups.
Personal attacks against any support-group members — including moderators — will not be tolerated.
Speculation on another person’s feelings or intentions.
Victim blaming or insensitive comments.
Shouting or angry voices.
Commercial promotion or solicitation.
We believe that each of you is an important element in creating an environment whether online or in person which will best provide the help, hope and encouragement for a brighter future. We want so very much to help you with achieve your respective visions.
With your signature below, it is understood that you accept your valuable role in growing together to improve our personal well being and also improving our children’s outcomes. Thank you for being a part of the MDR & Associates programs. Upon recommendation, you may be invited to join us in our continued growth and service to families nationally.
With much appreciation,
Mark Roseman, PhD, CFLE, Founder

After you fill out this form and submit it, you will be redirected to the Zoom link page. You can bookmark that page for your records.

860-271-3294

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THANK YOU for registering for our Support Group.
We are so happy you are here!

REGISTRATION

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Sign Up For Our Newsletter

860-271-3294

Email Us

Newsletter

THANK YOU for registering for our Support Group. We are so happy you are here!

REGISTRATION

Stay in Touch

Sign Up For Our Newsletter

THANK YOU for registering for our Support Group.
We are so happy you are here!