Co-Parent Empowerment Group
Shonnie Brown, M.A., MFT ~ 405 Chinn Street, Santa Rosa 95404 ~ (707) 526-4353
Happy Morris, M.A., MFT ~ 555 West College Ave., Santa Rosa 95401 ~ (707) 524-8876

Registration Form

name: _____________________________________________________________________________

address: ___________________________________________________________________________

phone (home): ________________   (work): ________________   (cell): ________________

Who referred you to us? ______________________________________

Were you ordered by Family Court Services to attend class?_____

    Which mediator did you see? ________________________________________

    Why were you ordered to attend? _________________________________________________

Is there a history of verbal/emotional abuse or domestic violence in your marriage? _____
    If so, please explain:  ___________________________________________________________
Is there a history of alcohol and/or drugs for you or the other parent? _____
    If so, please explain: ____________________________________________________________
If you were court ordered to attend, the facilitator of your class must release information about your attendance and participation to Family Court Services. Please read and sign this release, if applicable:
    I, ______________________________________, give my permission for the release and exchange of information about my attendance and participation in the Co-Parent Empowerment Group between Shonnie Brown/Happy Morris and Family Court Services.

    Signed _________________________________________   date ______________________

PLEASE NOTE: This form and the Participant Agreement Form must be read, signed and returned to the instructor with full payment ($180.00 for 6 classes) to ensure registration. Please do not send in forms without payment. Please make out your check to your instructor, NOT to Co-Parent Empowerment Group.


(for facilitator's use)

Registration form, signed participant agreement form and payment received ___________

Other parent's payment received ___________

Attendance: wk. 1 __ wk. 2 __ wk. 3 __ wk. 4 __ wk. 5 __ wk. 6 __

Release signed and report sent to Family Court Services ____________