CORE ENERGETICS SUPERVISION ENROLLMENT FORM

Please select all that apply. If not enrolling in a current group please indicate if you have future interest)

I am interested in small group supervisionI am interested in Indivdual supervision

If enrolling in a group please select the group from the list below

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

May we leave a message?

YesNo

Cell Phone*

Please enter a valid phone number.

May we leave a message?*

YesNo

May we text you?*

YesNo

Work Phone

Please enter a valid phone number.

May we leave a message?

YesNo

Email Address*

example@example.com

May we email you?*

YesNo

Emergency Contact Name*

Emergency Contact Phone *

Please enter a valid phone number.

Relation to Emergency Contact*

Race

Religion / Spirituality - describe any connection

Gender*

Pronouns

Sexuality

Learning / Physical Ability Challenges

Additional personal / cultural identifiers you would like me to know

Student or Graduate

Core 3Core 4Core 5Graduate

If graduate, what year did you graduate?

Are You Currently Seeing Clients?

YesNo

If yes, number of clients in your practice.

How many contact hours do you have with clients on average each week?

Please list any specific populations or any areas of specialties that exist in your practice (ie. Addiction, Fertility, BIPOC,LGBTQ, musicians, dancers, etc.)

Please list other licenses or certifications that you have that help to shape the work with your clients.

Please list any limitations on noise or movement you have in the space where you will typically participate from for supervision.

Location where you will typically participate in supervision. (Home, office, other)

Anything else you would like me to know.

GROUP MAKEUP

Groups are open to graduates of a Core Energetics 4 years training program and students enrolled in years 3, 4 or 5 of a Core Energetics training program.

SUPERVISION REQUIREMENTS FOR STUDENTS AT NY INSTITUTE

Core 3 = 14 groups sessions

Core 4 = 16 group sessions

SUPERVISION DATES & TIMES
Groups will typically meet every other week but may have to meet consecutive weeks on occasion.

The length of time will depend on the number in the group.
Minimum of 3 individuals required and maximum of 5 individuals per group. Groups are typically held on Tuesday / Thursday or Sunday afternoon / evenings.

5 participants = 1.5 hours
4 participants = 1.25 hours
3 participants = 1 hours

COMMITTMENT

If you arrive after the start of you’re the group, you will still be expected to pay for the session in full. 48-hour notification of not attending a group is required to avoid paying for the session.

16 SESSION GROUP: By enrolling in the group, you are committing to attending a minimum of 12 scheduled sessions. If you do not attend the 12 miniumn requirement you are still responsible for payment.

8 SESSION GROUP: By enrolling in the group, you are committing to attending a minimun of 7 scheduled sessions. If you do not attend the 7 miniumn requirement you are still responsible for payment.

FEE STRUCTURE (rates subject to change without notice)

Certified Practitioner $160 / hour for indivdual supervision

Student Practitioner $145 / hour for indivdiual supervision

Group Participant $75 per session

RECORDING

Select sessions may be recorded for the purpose of David deBardelaben-Phillips to receive supervision of his work.
This work would be shown to either in Core Supervision or Imago Supervision groups for Supervisors as David works to achieve advanced certifications. By participating in the group you agree to allow David to record select sessions. You will be notified before recording begins.

PHONE CALLS / EMAILS

There is no charge for phone calls or emails under 10 minutes as these calls are generally routine
calls (i.e. appointments).

Phone calls or emails over 10 minutes tend to involve client issues and a fee may be charged. The fee for these for every 15 minutes based upon hourly rates listed above.
Please note email is not confidential.

Agreement*

I have read and agree to the Policies & Financial Agreement.

Type Name of person signing. By typing my full name below and signing this form, I am affirming that I have read, understood, and agree to be legally bound by the Release of Liability, Financial Agreement, and Office Policies.

First NameLast Name

Client Signature *

Select preferred

VenmoZellePayPal (friends & family)Request invoice to be paid by credit card or ACH

CORE ENERGETICS SUPERVISION ENROLLMENT FORM

CONTACT INFORMATION

ABOUT YOUR PRACTICE

POLOCIES AND FINANCIAL AGREEMENTS

Release of Liability

Payment Options