Full name:
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Street address:
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City:
State / Province / Region:
Postal / Zip code:
Country:
Home telephone:
Mobile/cell phone:
Email address:
Profession / Vocation / Employment status:
Age:
Date of birth:
Family / Relationships (married/partnered, children):
Formal education: education, degrees, diplomas and training (completion date, length of training, etc.). Please write “None” if nothing to enter here:
Attach any certificates:
Description of professional practice (nature of practice, clients per week, years in practice). Please write “None” if nothing to enter here:
Attach any certificates:
Training in anatomy and physiology (course name, course provider, dates, number of hours of classroom attendance). Please write “None” if nothing to enter here:
Attach any certificates:
Previous craniosacral therapy training (including school, course length and hours of tuition). Please write “None” if nothing to enter here:
Health profile
Current state of health (illnesses, symptoms, registered disability):
Current and past medication (prescribed drugs, recreational drugs including alcohol/amount per week). Please write “None” if nothing to enter here:
Medical history
Physical (physical illnesses, accidents, falls, etc.):
Psycho-emotional (psychiatric, psychological processes that affected your functioning or well being). Please write “None” if nothing to enter here:
Hospitalisations, surgery (for physical or psychological reasons). Please write “None” if nothing to enter here:
Birth history and childhood (any known details, any relevant history). Please write “Not known” if history unknown:
Current therapy (current therapeutic modalities that you are experiencing as client/patient). Please write “None” if nothing to enter here:
Past experience of therapies (modalities that you have experienced as client/patient). Please write “None” if nothing to enter here:
Past criminal record (any criminal convictions). Please write “None” if nothing to enter here:
Any other information to support your application:
Please let us know how you heard about the course:
Personal Responsibility
The course is designed to provide insight and direct experience of this therapeutic approach. However, the course is not intended to be, nor may it be assumed to be, a treatment or cure for any existing complaint or illness, or for any complaint or illness that arises during the training period. It is the personal responsibility of each participant to seek appropriate support for his/her own personal wellbeing that is independent of the training programme. This may include having the assistance of a qualified Craniosacral Therapist between seminars to address any issues that arise during the seminar and training period.
All information that is asked for is given on a voluntary basis and is held in strictest confidence. None of the information, except the name, address and telephone number, is held on a computer database.
Financial Obligations
I am sending a £25 application fee with this form and a photocopy of any professional certificates. A course deposit of £500 will be due within two weeks of being accepted onto the training to confirm my place.
I understand that if I withdraw before the start of the course my deposit is non-refundable if my place cannot be filled. If a deposit is refunded, a £250 administration fee will be deducted. Once I have confirmed my place on the whole course, I understand that I am committing to the entire training programme and any payment of fees that has been agreed. Please note that the course fees (or the first payment if paying by instalments) are due at least three weeks prior to the start of the course.
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