Hold Me Tight® Couples Refresher Series
Hold Me Tight® Refresher Series
(Hold Me Tight® is trademarked by Dr. Sue Johnson)
This is a six session experience; once a month, for two hours each session. Strictly for couples who have previously taken a Hold Me Tight® Couples Workshop. This will be over zoom.
Dates: 12/1/2022, 12/29/22, 1/26/2023, 2/23/2023, 3/30/2023, 4/27/2023
Ideally, each couple commits to all six sessions but if you can only attend certain dates, you are welcome to do so and only pay for those dates.
Cost is $95 per couple per session and must be paid ahead of time. If you’d like to pay for the whole series at one time, you can pay a discounted amount of $525.
Each session is two hours long.
More information soon.
To Register: 2 Steps:
1. Fill out this form at the bottom of this page and send to drdiana@cottageclinic.net
2. Pay $95 for the first session or $525 for the whole series via Zelle, Venmo, PayPal, or check.
Mailing address if you choose to pay by check:
Diana Weiss-Wisdom, PO Box 3101,
Rancho Santa Fe, Ca. 92067
Zelle Information: www.zellepay.com
Zelle handle: drdiana@cottageclinic.net or (619) 405-4845
Venmo Information/handle:
Diana Weiss-Wisdom@Diana-Weiss-Wisdom
Your payment can also be paid via Paypal as FRIENDS AND FAMILY so as not to incur a processing fee, connected to my email: drdiana@cottageclinic.net.
You can cut and paste this form to your email and fill out and email back to me.
Hold Me Tight® Couples Refresher Series on Zoom with
Diana Weiss-Wisdom, Ph.D. Licensed Psychologist Psy#12476
INTAKE FORM
Please have each member of the couple fill out their own form. Your Name: ______________________________
Your Preferred Pronoun: ____________________
Your Partner’s Name: ____________________________
Date: _________________
Address: __________________________________________________
Home phone: ___________________
Cell phone: _________________________
E-mail: __________________________________________________
Referred by:________________________________________
Age: _________________ Date of birth: ____________ Relationship status: ___________________
Number of years together: _________________
What do you find most fulfilling about your relationship?
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How long have you and your partner been together? In what form? Dating, Living Together, Married?
__________________________________________________
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How happily partnered are you? Or what are the some of the best aspects of your relationship and the most challenging: __________________________________________________ __________________________________________________ __________________________________________________ ________________________________________________
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Number of marriages: ________________ Number of divorces: _________________ Number of children: _________________ Number of stepchildren: ______________
Occupation: ________________________
Emergency Contact 1 (name and number) __________________________________________________
Course Goals
What are you hoping to get out of this program? Please describe. __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
What was the most helpful part of the Hold Me Tight® Couples Workshop for you and your partner?__________________________________________________ __________________________________________________
Where and When did you take the Hold Me Tight® Couples Workshop?
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Cancellation Policy
Your registration fee is non-refundable.
Please confirm that you understand the Cancellation Policy by signing here: ________________________.
Please initial here: _______ to indicate that you understand that this is an educational and experiential series but not therapy.
Thank you!