Date

Phone(home)

(cell)

(work)

Name

Address

Date of Birth

Email

How did you learn about the Institute?

EDUCATIONAL BACKGROUND: Degrees held, major subjects, college or university name and location.

VOCATIONAL BACKGROUND: Present position, company or agency, jobs held now or in the past which are most relevant to work in the helping professions,approx. dates of past work.

PRIOR WORK IN GESTALT THERAPY and/or related humanistically-oriented seminars and workshops. Please name leaders worked with, location, pprox. dates of workshops, and approx. total number of workshop hours. Has your experience been predominantly academic or experiential?

Are you in therapy now, or have you ever been? If so, indicate what kind of therapy, with whom, and dates:

How do you want to use your Gestalt therapy training?