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Registration Form - Ancestral and Cultural Historical Healing Circle For Therapists

🗓️ Saturdays, April 25th, May 23rd, June 27th, July 25th, August 22nd - 11 AM - 12:30 CST
This form helps us get to know you before you join the circle. It’s an opportunity to share your professional background, your intentions for participating, and what you’re hoping to explore or deepen through this experience.

This group is designed for licensed therapists and mental health professionals who are interested in exploring intergenerational trauma, epigenetics, and the embodied impact of cultural and ancestral history. The circle includes both psychoeducation and guided process work. No prior specialized training in ancestral trauma is required — only openness to reflection and somatic exploration.

After you submit this form, you will receive information about how to join online sessions.

Please be sure to check your spam or promotions folder for emails regarding your enrollment.
Customer Details:
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Professional Title (e.g., LCSW, LMFT, LPC, Psychologist, Other)
Pronouns:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact (name, relationship, phone number):
What draws you to this group? (Briefly share what you're looking for in a healing space.)
Do you have any specific topics or challenges you’d like to explore in this space? (Optional, but helps me tailor the group to your needs!)
Are there specific ancestral, historical, or cultural dynamics you’re currently working on or curious about?
How do you tend to respond when you feel vulnerable in groups or relationships?
What helps you feel grounded or safe when you're emotionally activated?
Are you comfortable sharing and listening in a group space? (You won’t be required to overshare—but connection and presence are key.)
This group involves gentle experiential practices (like parts mapping, journaling, guided inner work). Do you feel open to this kind of process?
Do you have any access needs or concerns that would help me support you better in the group?
Is there anything else you want me to know about you, your journey, or what you’re hoping to receive from this group?
How did you hear about this group? (Social media, referral, website, etc.)
Would you like to receive occasional updates & special offers?
Confirmation and Agreement
I understand this live training is eligible for 1.5 CEUs and I will receive my certificate after filling out the course questionnaire upon completion of each session
I agree not to share the Zoom link or training materials without permission.
I understand that no refunds will be issued within 48 hours of the event
Group Therapy Policies: Fee The fee for this group is $100 for five sessions. Missed sessions will not be refunded, however, as a group we may decide to skip a meeting, in which case you will not be charged. This group is most effective when you attend consistently and honor the confidentiality of everyone present. What is shared in the group stays in the group.
This group is not a substitute for therapy and is not appropriate for individuals in acute crisis or active trauma processing. By applying, you're acknowledging that you're in a stable enough place to engage in group work with emotional depth and curiosity.
I confirm that I am over 18 years old.
Please indicate which session dates you want to attend. If purchasing the "drop-in"option, please reflect how many sessions you're purchasing today in the "quantity" field at check-out. Note, you may register for more later.

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All Five Sessions

$100.00 Quantity

Drop-in Session/s

Please indicate the dates you wish to attend above and indicate the quantity equivalent to how many sessions you are purchasing in the quantity listed below. Note that you my also choose to fill this form out again to purchase more sessions at a later date.

$30.00 Quantity

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Registration Form - Ancestral and Cultural Historical Healing Circle For Therapists

Confirmation and Agreement

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Payment Methods

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