Form | Re-Embody Life

Please indicate by clicking button below which option you are applying for:*
- Participant in ADVANCED LEVEL, LIVE Module C only
- Participant in Module A & B through AUDIO recordings, quizzes and demos + ADVANCED LEVEL, LIVE Module C
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Email:*
Professional Website
Date of SEP Certificate
List Your SE Teacher(s):*
Any Experience Assisting or Coordinating? If so, please explain:
Any Experience with AST Model? If so, please explain:
Experience with SE Faculty NonSE Trainings, such as Kathy Kain's Touch, etc. please list:
What is your license or background apart from SE:
How would you characterize your current client population? What do they struggle with the most?
Do you work in private practice? For an agency? For a medical institution or setting? For a recovery program or center? For a trauma center? Other? Please explain:
How is your work or the work with your clients connected to shame or shame-based issues?
What do you struggle with the most when working with shame?
How has shame impacted you personally?
What has worked the most effectively for you or your clients around shame resolution? If so, please explain:
How often have you used SE work around syndromes, energy wells, early trauma?
What do you hope to get from participating in this ADVANCED LEVEL Online Learning Experience?
Why do you want to take this particular course module?

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