REPARENTIVE THERAPY TRAINING

APPLICATION FORM

First Name

Last Name

Email

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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