Breaking Up is Hard to Do Workshop Series
Dear Participant,

Thank you for your interest in participating in our workshop series.  We have a few questions to help us determine whether this workshop is a good fit for you.  We want to emphasize that this workshop is effective when participants attend all 5 sessions and practice skills learned during the workshop outside of the meeting time.

Date & Time: Mondays from 4:30 pm - 5:20 pm beginning February 4th, 2019 and ending on March 4, 2019.
Location: Solarium (2nd Floor) - Davison Health Center
 
Your application must be submitted by 5 pm on Thursday, January 31st.  Applications are reviewed by Priya Senecal, LPC for appropriateness for the workshop, and all applicants will be notified by Friday, February 1st of their status with the group.
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Date:
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Last Name: *
First Name: *
Preferred Name: *
Email Address: *
Age:
Gender:
Class/Year:
Short-Answer Questions
How did you hear about our workshop? *
What sparked your interest in this workshop series? *
What do you hope to gain from participation in this workshop? *
Have you participated in any similar workshops or courses, and what did you learn from these that was helpful? *
Are you presently participating in any mental health treatment? *
Do you have any allergies or dietary restrictions we should be aware of?
Is there anything else you would like us to know about you?
Thank You!
Questions?
Please contact Counseling and Psychological Services (CAPS).  

Priya Senecal, LPC
psenecal@wesleyan.edu

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