Parenting through Infidelity On-line Support Group Registration

Full Name*

Partner's Full Name (if also attending support group)*

Phone Number *

Email*

Consent to contact - text, email or phone re: appointments, referrals or information.

Please tick the most accurate statement?

I am the betrayed partner/parent

I am the straying partner/parent

I am the child of parents who had an affair

I am the affair partner with a child

My child/children's ages and sexes are:

Please what you would like to learn in the Parenting through Infidelity workshop

Please share any relevant additional information.

How did you hear about The Seamless Blend?

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Referred by Previous Client

Family Mediators

Psychologists

Employee Assistance Program

Workplace People and Culture

Other Professional*

Google Search**

*If other Professional recommended TSB please provide their name

**If Google search, which search words did you use?

I understand The Seamless Blend do not provide crisis care or clinical psychological services, but offer a clinically aligned, evidence-centred, trauma-informed, child-focused, family-inclusive coaching model.

I agree to The Seamless Blend's Privacy Policy

I accept The Seamless Blend's Terms & Conditions

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