DW™/RS™ Questionnaire

Thank you for submitting this form.  Please complete the * sections to provide the confidential information needed to complete your registration.  The rest of the questionnaire is optional, however, your willingness to complete it will help me know you better as you embark on this journey.  Your participation in the workshop/group will be confirmed upon the receipt of your payment along with the submission of The Daring Way™ Questionnaire and The Daring Way™ Consent Form found under the "MORE" tab.  These may be electronically submitted or mailed to Justine Froelker 11457 Olde Cabin Rd., Ste 345 Saint Louis, MO  63141.

Name *
Address *
Phone *
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention?
If not, would you like referrals?