Toxic Family SUPPORT GROUP REGISTRATION - Mark Roseman & Associates

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

If you have any questions about this form or registration please email Ann O’Keefe or Bryan Hotlz, prior to your first meeting.

Full Name

DOB

Marital Status

Phone

Vocation/Profession

# of Years

Residence (street)

City

State

Zip

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?

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.