IFS Level I Prep Application

This class teaches you how to use Internal Family Systems, a powerful form of psychotherapy. This class is not psychotherapy, nor is it intended to replace psychotherapy or health care. The exercises you will do in this class may touch deep places inside you that can cause psychological, emotional, physical, or behavioral reactions. This reaction can occur unexpectedly and interrupt your sense of safety in a learning environment, despite efforts that are made to minimize this from happening. For some people, these reactions may be hard to deal with.

IFS is a very safe and respectful form of inner work, but for a few people this class may not provide the kind of individual attention and structure needed to feel balanced and safe while working on deep personal issues.

This survey is designed to help you think through how you will have the best experience in this class and give me a sense that you've made an informed decision and are ready for this work. If needed, outside of class, you and I will talk through any prior experiences you've had in IFS groups that have been difficult.

If you would like to discuss whether the class is safe for you, feel free to email or call Keith at keith@keithmillercounseling.com or 202-629-1949 ext 2.

The information shared on this form will not be viewed by anyone other than Keith Miller and is confidential.

Class Dates*

Name*

First NameLast Name

Email*

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Phone Number*

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Address*

Street Address

Street Address Line 2

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This course involves unsupervised peer-to-peer exercises. Explain your level of comfort adopting a "beginner's mindset" and viewing your peers as co-learners.

What professional discipline do you practice with clients? (i.e. social work, psychology, psychiatrist, clinical counselor, etc.) *

As your presenter, I will make every effort to ensure each person in our group feels that they belong and that all parts of them are welcome. This includes teaching the group how to speak for, instead of from parts, and keeping all members in coherence with the guideline of only speaking for their own parts. While I anticipate that the reward far-outweighs the small risk, there is always the chance that interacting with others in a group setting can create injury to some of our most sensitive parts. Explain how well you know your own capacity to provide internal and external support to your system. How you would help yourself remain connected to the group and to a learning-mindset, should one of your parts feel injured during our group interactions:*

What experiences have you had with Internal Family Systems Therapy? (i.e. IFS therapy, attendance at an IFS workshop or training or educational materials) *

What psychological issues are you facing now or want to parts of you would you like to work on? *

How much and how frequently do you currently use drugs and alcohol?*

Do you have any history of emotional instability? Please explain.*

If you experienced emotional difficulty or felt like you were falling apart, what steps would you take to regain stability?*

Are you currently in psychotherapy? For how long?*

I understand that the IFS IFS Level I Prep Course taught by Keith Miller is not psychotherapy or health care and is not intended to replace psychotherapy or health care.

I understand that even though the course content teaches a psychotherapy method, the exercises are intended to teach me skills for my personal growth. Exercises may involve accessing sensitive psychological material, and I declare that I have the psychological stability to handle whatever may come up.

I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Keith Miller or Keith Miller Counseling, LLC responsible for any pain or damages that may occur.

I understand that no continuing education credits are provided for this course. I further understand that a certificate of completion may be provided upon request, but is not guaranteed due to administrative constraints.

A check indicates I agree to the above disclaimer and my typed full name below is equivalent to my signature.

Signature: Please type your full name*

NEXT STEPS: Wthin 48 hours after completing this form you'll receive confirmation of your application and an invitation to enroll. At that time payment is due and you'll be directed to an online payment portal.

Thanks for your interest in learning IFS with me. This is amazing and fun work and I look forward to meeting you soon!

Keith

Application

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