Group Registration | You & Yours LLC

C.A.R.E. Program Participant Registration Form

First name

Last name

Birthday

Month

Day

Year

Phone Number

Email

Co-parent's name (First and Last)

How did you hear about this group?

If other, please briefly tell us how you heard about the group.

Relationship Status with Co-Parent (Please Choose one)

Divorced

Never Married

How many children do you have in common with your co-parent and what are their ages?

On a scale of 1-10, (1 = very low, 10 = very high) how would you rate the level of conflict with your co-parent?

What is your preferred group to attend throughout the next 10 weeks? (Participants will attend all 10 weeks in their assigned group.)

Thursdays from 8pm to 9pm

Saturdays from 9am to 10am

What is/are your reason(s) for attending this group? How will you know this group has helped? What would be different?

Do you currently have any restraining orders/protective orders or any other court order affecting contact with your co-parent?

Yes

No

Required Acknowledgment

Please review and acknowledge the following before submitting your registration:

Group Placement

I understand that I will be assigned to a co-parenting group that is separate from my co-parent, and that group placement is determined by the facilitator to support safety, neutrality, and productive participation.

Confidentiality & Participation Expectations

I agree to maintain the confidentiality of other participants and to follow the group's participation guidelines, including respectful communication and adherence to group boundaries.

Educational Nature of the Program

I understand that this program is educational and skills-based in nature. It is not legal advice, mediation, or a substitute for individual mental health or legal services.

Next Steps & Payment Process

I understand that submitting this form does not guarantee placement. Once my registration is reviewed and group assignment is confirmed, I will receive a separate payment link to complete enrollment.

Signature

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Date

Month

Day

Year

After submitting this form, you will receive a confirmation email. Group placement and payment instructions will follow once your registration has been reviewed.

C.A.R.E. Co-Parenting Program Registration