Somatic Art Group Registration Form

Name

First NameLast Name
Somatic art therapy group

Please fill out the form carefully for registration. The group will happen weekly via an online platform for around 2 hours per week. The group will have the same members throughout the 4 weeks. In each session, we will have a check in, a somatic exercise, around 30 minutes to make art. Then a chance to share your process and whats alive for you. During this time, if you are not sharing, you will be witnessing and holding space for the person who is exploring their art/feelings/sensations. We will close the session with a check out. All discussion and art will be confidential and the group is therapeutic in nature. Please do not sign up if you cannot commit to at least 3 sessions. Spaces are limited so please sign up early as spaces go fast! The group aims to begin on the first week of October 2023.
Birth Date

MonthDayYear
Gender
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Relationship to you
Email of Emergency Contact
example@example.com
Phone Number of Emergency contact

Area CodePhone Number
What is your previous experience of art therapy and somatic education (if any)?
What do you hope to get out of the group?
Do you have any mental health issues or significant things are working through? All answers will be kept confidentially and are useful for the therapist to know.
What are your strengths? What resources you?
Are you comfortable with using Zoom and email?

YesNoI have basic knowledge but could use more support
Can you commit to a two hour live session each week?

YesNoI am away some of the dates
What time zone do you live in?
Which group do you want to join?

Sept 12 -3rd Oct Tuesdays 10.30 - 12.30pm PSTOct start (please select a time below)
Which group can you join (please select all that work)?

Tuesday 10.30am-12.30pm PSTTuesday 4-6pm PSTThursday 10.30am-12.30pm
Do you agree to pay $25-40 for each session to Kate Leppard for this course via PayPal or e-transfer (Canada or UK)

YesNo
Please specify amount you will pay each week
Please send a Paypal or e-transfer to kateleppard@gmail.com of $25 to secure your place (This will be offset against your first week's payment or returned if you are not accepted to the course)

Done
Do you agree to keep confidentiality for all group members?

YesNo
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