www.esalen.org Application Form www.sbgi.edu
Embodied Therapist Certificate Program
Santa Barbara Graduate Institute and Esalen Institute
Name Date
Mailing Address City and State
Email Address Zip Code
Daytime Phone Evening Phone
Date of Birth Gender:
 
I am applying for (please check one of the following):




 

Individual Course Dates:

July 6-11, 2008 Feb/Mar 2009


 
Do you currently have a license to practice some form of therapy?  If so please specify type and how long you have been in practice.
 
Do you currently have a bodywork or somatically oriented practice?  If so please specify type and how long you have been in practice.
 
Do you have a practice or experience providing therapy, counseling, consulting or heath care not covered above?
 
Do you have other relevant professional background and experience?  Please specify type and length.
 
Do you have any medical condition that may interfere with your capacity to participate in this program?
 
 Do you have any psychiatric condition that may interfere with your capacity to participate in this program?
 
Is there anything else that you would like us to know?
 
Participation Agreement:

I understand that this program includes exercises and topics that could be stressful.

I understand this program will include the use of touch, personal and interpersonal exercises, and therapeutic practices.
 
Hold Harmless Statement

I understand that I am responsible for my own actions during my participation in the Embodied Therapist Certificate Program with faculty and associates of Santa Barbara Graduate Institute. And that Santa Barbara Graduate Institute and their associates, Esalen Institute and their associates, and the owners of the property where the training will be held assume no responsibility for any incidents or accidents to any individual.

This Certificate Program is for professional and personal self-development and informational purposes only and is not intended to be therapy. Participants seeking or requiring professional therapeutic services should secure them from a private therapist outside the training.

 
I agree with the above statements and by submitting this application am applying my signature.


 
After submitting this application you will be redirected
to the beginning of the Embodied Psychotherapy Course section.