Family Circle Request Form

Role of the Person Completing this Form

What Services are you Interested

Watch Recorded Training Video(s)

Participate in live Empathy Circles via Zoom

Contact Information

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dispute/Issues

Please briefly describe the issue that led you to seek the services chosen above.

By participating in the chosen service(s) What are your goals or what do you hope to gain from it?

Any other information you want to share?

Payment Policy

Training Videos: Each recorded training video is available for $50.
Empathy Circle Practice Sessions: Participation in an Empathy Circle practice session is priced at $100.
Non-Refundable Payments: All payments are non-refundable.
Video Access: Once the link to the recorded videos is activated, participants must complete watching within 24 hours.