PART 1: REGISTRATION INFORMATION

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If you have children, please give the ages of each and briefly describe your relationship with them.

Degrees held, if any:

What other workshops or seminars have you participated in, and approximately when did you take them?

What organizations or special interest groups are you involved in?

Who referred you to Life Design Education?

What are your top three greatest strengths?

What are three of your greatest challenges?

What are your three most important goals?

Describe what you would have your life be like if you had the opportunity to reinvent yourself.

What outcomes or personal value do you intend to create by participating in this training?

What personal and professional accomplishments are you most proud of?

What specific assistance do you want or need from the course facilitator and staff to make your participation most effective?

PART 2: HEALTH INFORMATION

Answer the following questions honestly and completely. When a question is not applicable, write "N/A" in the space. Please be aware that this information is NOT intended to be used by Life Design Education for the purposes of screening. Life Design Education programs are experiential, educational programs; they are neither psychotherapy nor medical therapy. Life Design Education does not and cannot screen its students. Only you can decide what is right for you, and the information provided here is to assist you with that decision. In the Life Design Education trainings, you will be invited to examine your life and various issues regarding your life. You should be aware that if any of the issues have sadness or difficult feelings and emotions attached to them in the normal course of your life, it is likely that these same feelings and emotions will emerge in the Life Design Education courses. You must decide whether this is something you can handle at this time. Your willingness to experience these feelings and emotions honestly, and then let go of them, can open the way to a more joyful experience of living. The choice to do so, however, and the degree of your participation in the process, rests with you alone. The information requested here is meant to enable Life Design Education to better support you during the course. It is not possible for Life Design Education to predict any student’s experience. If during the course you find yourself feeling uncomfortable or need assistance, notify the staff immediately.

Please list any medical issues that the course facilitators and staff should be aware of. This includes both physical and emotional/mental health issues, conditions, treatments, therapies, and medications you are receiving.

Please be specific.

Have you ever been hospitalized for psychiatric care or mental disorder? If yes, when?

If yes, please state when.

IMPORTANT NOTE: REQUIREMENTS FOR PARTICIPATING

If you have any physical problems that may make it difficult for you to participate in the Life Design Education courses, it is recommended that you discuss this with your physician to determine the appropriateness of your participation. You MUST consult with a professional counselor, therapist, or physician and obtain a signed statement that there are no therapeutic contradictions to your participating in the Life Design Education courses if any of the following conditions apply: 1. You have been hospitalized for a psychiatric or psychological disorder within the last five years. 2. You are currently in therapy for psychological difficulties or problems or have stopped this therapy within the last six months. 3. You have been prescribed within the last six months or are currently taking any major tranquilizer or antidepressant medication such as Lithium, Thorazine, Stelazine, or Haldol. If any of these conditions apply to you, you must request a copy of this online form and a copy of the "Notice to Professional Counselor" letter from Life Design Education. This online form and letter must be presented to your therapist or prescribing physician to have him/her read the form and the "Notice to Professional Counselor" letter in its entirety and discuss the advisability of your participation. If he/she agrees there are no therapeutic contradictions, have the letter be signed and dated by all parties.

PART 3: EMERGENCY CONTACT INFORMATION

Please provide the name, relationship, and phone number of TWO (2) emergency contacts who Life Design Education may contact during the training, in case of of an emergency.

Relationship

(Mother, Husband, Daughter, Neighbor, Co-Worker, etc.)

By typing your first and last name below, you hereby acknowledge and attest that you have thoroughly and carefully read the information contained herein, that you understand it and agree to it, that you have answered all questions truthfully, and that you have fulfilled the requirements for participation in this training.

Detailed StudentInformation Form

Detailed Student
Information Form