Embodyssage Mentorship Training Program Application

Mentorship Training Program Application Form

For the Embodyssage Mentorship Training Program, these questions are designed to help through the process of an initial virtual clarity call to gather background information for internal purposes only and are kept confidential.
Personal Information
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Time Zone:
(Pacific Time, CT, ET, etc.)
Email
This will be used to communicate regarding appointments and/or questions you may have.
Client Phone Number
You will not be called/texted unless you have provided consent to do so in the service agreement should you enroll into the program with Embodied Elements.Format: (000) 000-0000.
Emergency Contact Name
By filling this out, I give my consent for Embodied Elements, Lucia Vasquez, to contact emergency name listed ONLY in the event of an medical emergency (no individual session details will be disclosed).
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
- What is your birth sex, gender identity, and sexual orientation if any?
  (female, male, intersex, etc.); (Cisgender, Nonbinary, Transgender, Genderfluid, etc.); (bisexual, heterosexual, pansexual, etc.)
- Preferred Pronouns if any?
  (she/her, he/him, they/them, etc.)
- Occupation if any:
- Website if you have one, please share:
- Do you have children? If so, how many?
- Will you need a payment plan?
- Do you have any medical or health conditions? Please share details:
- Do you have any accessibility needs? If so, please share:
- Do you have any passion projects you're currently working on that you'd like to share?
- Are you currently studying with other teachers, mentors, programs, etc.? If so, please share:
- What courses, classes, workshops, trainings of similar field have you taken?
- Do you have any experience in any form (legal and/or underground) with bodywork? Please share:
  Please list any areas on the body with scar tissue (small and/or large).
- What is something you'd like to take away from this Mentorship Program? Please describe:
- Are you actively engaging in practice to dismantle systems of oppression? What does this mean to you? Please describe:
- In any deepening practice, strong sensations and emotions can arise, this is expected to some extent. In your won self assessment, are you in a place where you can join in a space that might be emotionally activating? Please share:
- Embodyssage Mentorship Training Program is a trauma informed program, but Embodied Elements, Lucia Vasquez, is NOT a trauma therapist. Given that these sessions and process are likely to stir up traumas, etc. we want to ensure that you have support systems in place. If you have significant sexual and/or childhood trauma, it is recommended to have sought counseling or are currently in therapy as additional support. Do you currently have a support network available? What does this look like? Please describe:
  Please inquire about additional resources and referrals if needed.
- Thank you so much for taking the time to share with me, I appreciate you. Is there anything else not already mentioned above that you would like to share with me at this time?
- Please check the box to indicate that you understand and agree with the following:
- - These questions are designed to help through the process of an initial virtual clarity call to gather participant history and background information for internal purposes only and are kept confidential. At no given point is information disclosed or shared without client's written consent. This application form is stored within the Jotform website and provids end to end encyption for privacy. This means that your submission is kept private and secure.
  - This application process may stir up trauma and associated memories. You may need additional support to process in the days following the completion of this intake. It is important to ensure you have a reliable support network available. Please inquire about additional resources and referrals if needed.
  - You may contact Embodied Elements, Lucia Vasquez, at lucia@embodyssage.com for any questions and/or concerns.
  - I understand, have read, and completed this form to the best of my knowlege.
  - I give consent for an intial virtual clarity call from Embodied Elements, Lucia Vasquez.
  - I acknowlege that Embodied Elements, Lucia Vasquez, has the right to terminate the session at any time.
  - I understand that withholding information or providing misinformation may result in contraindications and/or irritation from any sessions.
  - I release Embodied Elements, Lucia Vasquez, from any and all liability associated with any injuries/current and future conditions and assume full responsibility therof.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Signature
  
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Mentorship Training Program Application Form

Personal Information