Skillful Parenting

REGISTRATION FORM

Thank you for your interest in our group! Please complete the following and our team will connect with you for additional screening.

Name*

First Last

Date of Birth*

Email Address*

Phone Number*

Street Address*

Address*

City* State*

Zip Code*

What is your family’s service branch?*

What is your family’s current military status?*

Emergency Contact*

Full Name Phone Number

How many children are in the household?*

What are their ages?*

What is your main challenge with respect to parenting?*

The Mass General Brigham standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Mass General Brigham. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Mass General Brigham will not be held responsible. Your preference to receive unencrypted email will apply to:

For research: Emails sent to you from research staff in this study. If you wish to communicate with other research staff at Mass General Brigham regarding additional studies, your preference will have to be documented with each research group.

For clinicians: Emails sent from clinicians and staff at this practice or department.

Permission to email unencrypted messages?*

Yes

Would you like your spouse, partner, or secondary caregiver to attend? We would love to have them! Please be sure to have any additional guests register separately so we can better account for the total number of participants.