TITLE AND DATE OF EVENT YOU ARE REGISTERING FOR:
___________________________________________________________________
Name & Pronouns___________________________________________________
Address ____________________________________________________________
Phone ______________________________________________________________
Email ______________________________________________________________
How did you hear about this event?
Please give us a sense of your life experience and include any history of trauma or other life difficulties.
What is your experience with therapy and body-psychotherapy?
What is your relationship to substance use at this time in your life?
What are you hoping to get out of your time here?
Do you need Continuing Education Credits? Y N
What is your licensing body? ____________________________________________
Please send your completed form via email. Otherwise copy, print and mail with your payment to the address below. Email for Zelle payment options, or if you prefer to pay by cc (add 5%) please call 206-910-9766 and send your form via email.
For other payment options, please contact Aylee.
Body-Psychotherapy of Seattle & Seattle School of Body-Psychotherapy
2515 NE 107th Street Seattle, Wa . 98125