Training Application

Thank you for considering the Arizona Gestalt Institute. The application process is for those interested in the 1st Year Intensive. The purpose of the application process is to gather general information in an effort to ensure this training opportunity will meet the needs of all involved. There are two parts to the application process: First, is this written questionnaire and second is a phone interview. There is a $75.00 fee attached to the application process. If an applicant is not accepted into the training program this fee will be reimbursed. If an applicant opts out at anytime during the application process the $75.00 fee will not be reimbursed.

Gestalt Training Application

Name *

First

Last *

Last

Address *

Address Line 2

City *

State *

Postal Code

Home Phone *

Cell Phone

Email *

How did you hear about the Arizona Gestalt Institute?

What is your educational background?

What kind of work are you currently doing?

Do you have any formal psychotherapy training?

Yes

No

Have you ever been diagnosed by a mental health professional with a personality disorder?

Yes

No

If yes, please explain what the diagnosis was.

Are there any specific needs you have that would be important for us to know?

Yes

No

If yes, please explain

Will you be seeking a partial scholarship through the Arizona Gestalt Institute?

Yes

No

Why do you want to participate in this training program?

I find myself in my vulnerability
It’s only intensity
It’s complex and trivial
Individuality is all
If you don’t do conflict you do alienation
You can ask for everything
Willing to have the wound of Love
Exceptional experience is crucial
Tap into the flow of your awareness

Phone

(928) 848-1111

Email

info@azgestaltinstitute.com

Street

Address

3259 N. Wisdom Way
Prescott, AZ 86305

Training Application

Phone

Street

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