The Leela School of Awakening Application Form
Psilocybin Facilitator Training Program Application
Personal Information
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Name
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First Name
Last Name
Phone Number
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Email
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Address
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Street Address
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Date of Birth
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Gender
Are you a US Citizen?
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Are you a resident of Oregon?
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Have you served in the US military / armed services?
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If you answered Yes to the previous question, were you Honorably Discharged?
Have you ever applied to The Leela School before?
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If you answered Yes to the previous question, when?
Have you ever attended The Leela School before?
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If you answered Yes to the previous question, what did you attend and when?
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Relationship
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Education
Did you complete high school / secondary education?
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GED
If you answered Yes (or GED) to the previous question, please provide the year of graduation:
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Please tell us if you have completed postsecondary education including the name, location and degree of received postsecondary education:
Are you fluent in the English language (written and spoken)?
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Employment
Please describe your occupation:
Are you currently employed?
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Yes, less than 35 hrs per week
Yes, more than 35 hours per week
If you answered Yes to the previous question, please specify the name and contact details of your current employer:
Ethnicity
What is your National Origin?
Are you Hispanic or Latino?
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Regardless of your answer to the prior question, please indicate how you identify yourself (select one or more):
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American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Your Motivation
I am pursuing admission into the Leela School Psilocybin Facilitator Training Program for the following reason (choose one):
Career preparation and employment
Personal development / Self improvement
Advanced Training / Continued education
How did you discover our program?
Google search
A friend's recommendation
Direct engagement by the organizers
Facebook
LinkedIn
InstaGram
Social Media (other than above)
Newsletter
List of accredited programs on the OHA website
Other
If you said Other above, please tell us where:
What inspired you to learn about and work with plant medicine?
What makes you resonate with our program in particular vs. other psilocybin facilitator programs?
What do you want to experience, learn and gain from this program?
What would be (a) good outcome(s) for you at the end of our time together? How would you recognize a good outcome - what would be the signposts?
Do you feel ready and capable to commit to the full duration of our program? What do you see as potential challenges to this commitment (if any)?
You are welcome to upload your CV/resume here (optional)
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