Name
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Name
First Name
Last Name
Date of Training
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Date of Training
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Address
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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Date of Birth
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Cell Phone
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Cell Phone
(###)
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Other Phone
Other Phone
(###)
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Confidential Health Information
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Please answer all of the following questions. Your answers will be kept confidential. The information requested here is to enable us to better support you in the training. However, it is not possible for us to predict any participant’s experience. If during the training you find yourself feeling uncomfortable to a degree that you think is excessive, we request that you report this immediately to the trainer or a staff member.
If you have any question about whether or not you should participate at this time, please consult a professional. In some cases, we will require that you do so.
1. Are you currently in therapy? (If yes, see “Section A” below before continuing.)
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2. Have you had any prior therapy or psychological counseling?
Section A
If you answered “Yes” to question 1 above indicating that you are currently in therapy, we suggest that you discuss with your current therapist the advisability of your taking the training at this time and sign the “Personal Release” below.
We urge you to fully express to your therapist any concerns you may have, and listen closely to any concerns your therapist may have for you. We strongly recommend that you follow your therapist’s advice as to whether or not this is an appropriate time for you to take the training. If your therapist requires more information, he/she is welcome to review this form, and/or call the local sponsors.
Personal Release (optional)
I have talked with my therapist, (print therapist’s name)
First Name
Last Name
Date
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1. Have you ever been hospitalized for psychiatric care or for a mental disorder?
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If yes, give approximate beginning and ending dates:
2. Are you currently taking or have you ever been prescribed any anti-psychotic medication such as Thorazine or Stelazine?
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3. Are you currently taking or have you ever taken medication for psychosis, schizophrenia, bipolar disorder?
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4. Do you have any medical condition(s) that may be aggravated or inhibit your participation in the training?
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If yes, please describe:
5. Have you ever been incapacitated by severe depression, anxiety, or other mental disturbance?
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6. Have you ever harmed or threatened to harm yourself or become violent toward others?
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If yes, was there a direct suicide attempt? When?
When was the last time you contemplated or fantasized about suicide?
Did you seek help? Please specify.
7. Within the last 12 months have you been dependent on alcohol, marijuana, cocaine, or any similar non-prescribed drugs?
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If yes, describe:
8. Have you ever experienced any events in your life that resulted in significant trauma from any kind of abuse (i.e., physical, emotional, mental, verbal, sexual, or spiritual)? Have you ever experienced significant trauma from a loss of a loved one? Have you ever experienced significant trauma from any other significant loss? If yes, please describe.
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Emergency Contact
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In case of emergency contact:
First Name
Last Name
Relationship
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Home Phone
*
(###)
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Other Phone
(###)
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Verification
I hereby acknowledge and attest that I have thoroughly and carefully read the information contained herein, that I understand it, that I have answered all the questions fully and truthfully, and that I take full responsibility for my participation in The Encounter training.
First Name
Last Name
Date
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