SOMATIC EXPERIENCING®
Name __________________________________________________
Address_______________________________________________________________________
City _____________________________________________State _________Zip ________________
Phone (W)________________________ (H)
_____________________
(C) ________________
Email: ____________________________________________________________
Level of Education: □BA/BS □ MA □ Ph.
Professional
Occupation: _____________________________________________________________
Health Care License? □ No □ Yes State: ____ License #: _______________ Expiration
Date: _________
Do you have any grievances, complaints or actions pending or upheld
against you for misconduct as a professional by any licensing, regulating or
associative body?
□ No □ Yes If yes, please provide full details and
copies of all relevant information.
* Submit the following required
documents with this application and fax or mail to the FHE:
1.
A current Curriculum Vitae (resume)
2. A professional biography which
includes brief descriptions of the following: personal trauma you have
experienced, description of your current practice, # of clients you see each
week & a short statement indicating your primary interest in learning SE®
(1 page)
Registration for Beginning
I Training
Location of training
(City/State): _______________________________________________
Dates: _____________________________ Instructor: ________________________________
How did you hear about
this training?
□ Flyer □ Colleague □ SE Fundamentals / Introduction
□ Conference Presentation
□ Professional Publication (name) _________________________ □ Other ___________________________
Payment: Make Checks payable to the FHE in US Funds. Visa and MasterCard
accepted.
TOTAL ENCLOSED_________________________ □ Check □ Visa □ MasterCard
Credit Card Account # _______________________________________________________________
Exp. Date___________________ Signature_____________________________________________________________
All information
submitted will be held in strict confidence. You will be notified by email of
your acceptance into the program. The FHE
reserves the right to reject applications, without explanation, and will
provide a full refund.
The FHE reserves the right to cancel and /or reschedule any
Beginning I class due to low enrollment 30 days prior to the start of the
class. Should your class be cancelled, you will be notified as soon as
possible. A full tuition refund will be issued or the funds may be
transferred to another Beginning I class. Please note: The
FHE is not liable for expenses incurred due to cancellation, including but not limited
to airline cancellation fees or hotel cancellation fees.
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