The Daring Way™ Group Registration 2017-05-23T11:58:50+00:00

“May whatever suffering arises serve to awaken compassion. “

-Tara Brach

Registration for The Daring Way™  Spring 2017 cycle is currently underway! The group will run on Thursday evenings (6:30-8:30pm) from  5/4-6/22.    Registration will close on April 27th.

Thank you for submitting the registration below.  Please complete the * sections to provide the information needed for your registration.  The rest of the questionnaire is optional, however, your willingness to complete it will help me know you better. Your participation in the group will be confirmed upon the receipt of your payment along with the submission of The Daring Way™ Questionnaire and The Daring Way™ Consent Form.  These may be electronically submitted or mailed to me at Sarah Perl, LCSW-R,  291 Broadway Suite 1401, New York, NY 10007.  Printable Registration Form

Name:*
Address:*
Phone:*
-
E-mail:*
Would you like to be included on my e-mail list about future events? *
How did you hear about this workshop?*
Of the upcoming meeting dates, are there any dates that you know now that you are unable to attend?*
The below fields are not required, yet they are needed to complete your registration. Please note that this form is not HIPAA compliant. If you wish to phone in your answers, please indicate so below and I will reach out by phone. You can also print and mail this form through the link above. *
Emergency Contact Name and Phone Number
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
If YES, when? Please briefly list the reasons and outcomes:
Do you have a therapist you could work with if something came up in this workshop requiring more in depth individual attention?
If yes, would you like to sign a consent for me to be able to coordinate care if needed with your therapist?
Areyou currently taking any medication for mental health issues?
If yes, please explain:
If not, would youlike referrals to therapists?
Are you currently using or in recovery from any substances or alcohol? If current, what do you use and how often? If in reco very, how long have you been sober? Please provide a brief descriptio n of the treatment and support you receive for maintaining your sobriety?
Do you have a history of an eating disorder or disordered eating? If so, please provide information on the support and treatment you have received.
What sparked your interest in this group?
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues.
What would you like to accomplish as a result of attending the Daring Way™ group?
What previous experience have you had, if any, with group therapy or a support group?
Please list dat es and the name of the group.How were they helpful?
What difficulties did you have, if any?
What concerns, if any, do you have about participating in a group experience?
How would you respond as a group member if someone in the group dominated the discussion?
How would your respond as a group member if someone never participated in the group discussion?
What else would you like me to know about you?
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Informed Consent

Registration for The Daring Way™  Spring 2017 cycle is currently underway!   The group will run on Thursday evenings (6:30-8:30pm) from 5/4-6/22.  Registration will close on April 27th.

Thank you for submitting the informed consent below.  Please read the form below and sign. Your signature indicates that you understand and agree with the content of this form.   Your participation in the group will be confirmed upon the receipt of your payment along with the submission of The Daring Way™ Questionnaire and The Daring Way™ Informed Consent Form.  These may be electronically submitted or mailed to me at Sarah Perl, LCSW-R 291 Broadway Suite 1401 New York, NY 10007.

This is a psycho-educational experience. This means that you will be experiencing interplay between education, and personal processing and growth.  This process is presented as an intensive one or two day workshop, or in a weekly group setting.  

Participation in this experience can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek attendance at a psycho-educational process.   During the psycho-educational process you may also encounter unpleasant feelings or thoughts.  You may also make decisions about changes you would like to make in your behaviors and/or relationships.  This experience may result in changes that were not originally intended.    During the course of a psycho-educational process, Sarah will draw on Dr. Brené Brown’s shame resiliency theory. Attending a psycho-education process is not a substitute or alternative for individual psychotherapy or inpatient treatment. If you are in need of names of counselors before, during, or after the psycho-educational process, Sarah would be happy to discuss this with you and offer a referral.  

I understand that I am agreeing to participate in a psycho-educational experience that carries with it the potential of positive benefits and/or unpleasant feelings. I understand that I may experience both expected and unexpected change. *
I understand that this is not a substitute or alternative for individual/couple counseling, and that I am free to participate in my own counseling during, or after this experience. I also agree to practice self-care while I participate in this group. If I am feeling overwhelmed, I will slow down, or take a break and step away. I understand that I am free to participate to whatever degree is comfortable for me, and I will not push myself beyond that to meet any perceived expectations of myself or others.*
E-mail:*
Please type your name below for signature:*
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