Complete the Application Form for
the Somatic Mentoring Consult Group.

Practitioners with active caseloads are invited to register.

Please complete the Application Form, answer each question with as much detail as you can. It will help me know more about you and your background!
Read and accept the Disclaimer Statement!
Now you can pay for your program. Ta-da, you’re in! (if for any reason you need to split the payments into 2, please let me know by email and we will work that out)

Basic Information

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender and other Identities You Lead With

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

Country

(###)

###

####

Time Zone

Background

Degree(s), Specialties, Trainings, Approaches and Therapeutic Talents + type of clients you see

Do you have any background in Somatic work yet? Please describe

How much personal healing/somatic therapy have you received yourself?

What are your burning questions you'd like addressed?

Be brave and describe!

What activities or practices do you use to help keep yourself healthy and regulated? What struggles do you deal with, as well?

How have you been doing during the COVID shelter in place?

I'm all ears!

3. Thank you for filling out the Form so I can learn more about you!