SE Registration - The Healing Circle

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How many languages are you fluent in? Please list below. *

Level of Education- please choose all that apply *

Professional Title *

Dr
Mr
Mrs
Ms

Areas of Specialisation *

How long have you been in practice? *

Describe your Professional Practice: *

How many patients/clients do you see on a weekly basis? *

If you do not have a professional practice, are you a student in a Psychology-oriented Master's program? *

Yes
No
Not Applicable

Do you have any physical disabilities or learning difficulties(such as dyslexia)? *

Yes
No

Do you have any Psychiatric or Medical history? Please give us details of any psychiatric or medical conditions you may have had from the past or present. *

Have you been a part of psychedelic assisted therapies? *

Yes
No

If applicable, please provide an example of any additional relevant professional training, education and/or professional experience(s) (not already included in your CV/resume or previous answers) that may have prepared you for the SE™ Professional Training: *

Briefly state your reason for applying to take the Somatic Experiencing® Professional Training: *

I've had a major traumatically-stressing event within the past year: *

Yes
No

I understand that the SE™ Professional Training may trigger past traumas: *

Yes
No

Do you have any grievances, complaints or actions pending or upheld against you for misconduct as a professional by any licensing, regulating or associative body? *

How did you hear about the Somatic Experiencing® International's professional training program? *

Please enter the full name and location of the person who referred you. *

Resume/CV Upload *

Click or drag a file to this area to upload.

Maximum file size is 10MB.

Terms *

I have read and agreed to the statements above and by submitting this application, I understand that if I receive acceptance to this training program, ONLY my registration with payment secures my space, and I will need to make this payment as per the timelines.