Application for Participation in Healing Ties

Name

First Name

Last Name

DOB

YYYY

City/State

Phone

(###)

###

####

Message

Family Information:

Names and Ages of Family Members Participating:

Briefly describe your relationship with each participating family member:

Background and Story:

How have these issues impacted your family dynamic?

Have you and your family members previously attempted to resolve these issues?

If yes, please explain how and why it may not have worked.

Motivation for Joining:

What outcomes are you hoping to achieve through this experience?

Personal Reflection

Are you willing to accept responsibility for any role you may have played in the conflict?

If yes, are they supportive of your participation in Healing Ties?

Do you or any participating family members have any health concerns that the production team should be aware of?Do you or any participating family members have any health concerns that the production team should be aware of?

Final Thoughts

Agreement and Signature

I, ____________________________ , certify that the information provided above is accurate and complete. I understand that participation in Healing Ties involves exploring potentially sensitive personal topics and that the purpose of the show is to promote healing, not confrontation. please copy this and re-paste this in the box below with your name to consent and then sign your name below.

Signature

Date

YYYY

Application for Participation in Healing Ties

Power