REPARENTIVE THERAPY TRAINING
APPLICATION FORM
First Name
Last Name
Phone/Mobile
Your website
Address
Address Line 1
Address Line 1
City
State
Zip Code
Country
Phone/Mobile
I can receive texts
About Your Practice
What sort of license do you have?
How many years have you been in practice?
Are you in private practice? If not, what setting do you work in?
Are you working in person, via video or a hybrid of both?
What is your niche/what clients do you generally see in your practice?
What challenges might arise for you personally as you work with people with developmental trauma?
Your training
What healing modality/ies are you trained in?
What training do you have for handling trauma as it arises?
Personal
Are you in therapy?
What’s your personal experience with trauma?
What are your triggers?
How do you know when you’re triggered?
What are your self care practices?
This program
What interests you about this program?
How is it for you to be in the role of student?
How do you receive constructive feedback?
What do you think might be your vulnerabilities in this program?
Are you able to attend 10 Friday sessions March 1-May 24 (exact timing TBD)
Anything else you think we should know?
Phone/Mobile
How did you hear about ReParentive Therapy and this training?
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