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Integrated Prenatal and Perinatal Dynamics Workshop application

PART 1

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Email Address

Occupation

Age

Date of birth

Gender

Family/relationships

Married, partner, children, etc.

PART 2

Craniosacral Foundation Training Certification

Instructor/Institution - Completion Date

Previous Craniosacral Therapy Training

Course - Length of Course - Hours of Tuition

Training in Anatomy and Physiology

Course - Length of Course - Hours of Tuition

Degrees and Certificates

Course - Length of Course - Hours of Tuition

Professional Qualifications

(e.g., association registration, etc.)

Clinical Practice

Years in practice, number of clients per week, specialties, etc.

Current and Past Medication

Prescribed and recreational drugs, including alcohol, amount per week

Physical

Physical illnesses, accidents, falls, etc.

Psycho-emotional

Psychiatric, psychological processes that affected your functioning or well being

Hospitalizations, Surgery

For physical or psychological reasons

Birth History and Childhood

Any known details, any relevant history

Cranial Experience

Your experience as a client to date, approximate number of sessions taken, any experience of Biodynamic Craniosacral Therapy? etc.

Any other relevant information

Any other information to support your application