Connection Reclaimed!

REGISTRATION FORM

Thank you for your interest in Connection, Reclaimed. Please complete the form below to reserve your spot.Once received, we’ll follow up with payment details & invoice links.

This workshop is limited to 10 couples to ensure depth and support.

Your Full Name

First Name

Last Name

Your Partner’s Full Name

First Name

Last Name

Your Email Address

Your Partner’s Email Address

Phone Number

(###)

###

####

How did you hear about this workshop?

Social Media (Instagram/Facebook, etc.)

Referral

Jessica

Luis

Other

A few short questions to help us hold the space well:

What drew you to this workshop?

How many years have you and your partner been together?

How would you describe the current state of your relationship?

What do you each hope to gain from this experience?

Are there any significant mental health issues present for either of you and if yes, are you receiving professional support for those issues? (Ex. depression, PTSD, suicidal ideation etc.)

Accessibility & Accommodations

Do you or your partner have any allergies or dietary restrictions we should be aware of?

Are there any accessibility needs, sensitivities, or special accommodations you'd like us to consider?

Is there anything else you’d like us to know before the workshop?

Agreement & Payment:

I understand that my spot is not secured until full payment is received.

I acknowledge that the workshop is not a replacement for therapy or clinical care.

I agree to respect the confidentiality and privacy of all participants.

Early Bird Pricing ($1,500 + HST per couple) is available until August 15. After that, the full fee is $2,000 (plus HST) per couple. Receipts for a portion of the fee are available to submit to your health insurance provider if desired.