Thank you for your interest in The Daring Way™ Intensive!

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.  These may be electronically submitted.

*You will automatically be taken to The Daring Way™ Consent Form after this submission

Name *
Intensive Date You'd Like to Attend
Intensive Date You'd Like to Attend
Address *
Phone *
Have you ever worked with a mental health professional before? *
Do you have a therapist you could work with if something came up that requires individual work? *
If not, would you like referrals? *

Please contact Justine at if you have any questions.