Craniosacral Therapist Training Program Application

Application for Craniosacral Therapist Training Program with Peggy Reynolds
The application form is to support you in your journey as a craniosacral therapist. The information given in this application is kept confidential. Course participants are asked to have some knowledge of anatomy, physiology and experience in some form of body oriented therapy. Class size is limited and candidates will be admitted on a basis of date of application, degree of experience, ability to benefit from the class, meeting of pre-requisites and willingness to follow agreements set forth by teaching faculty in respect to the safety of self and others.
A $250 non-refundable deposit is required below to submit this application and schedule your interview. The deposit will also hold your spot in the program if your application is approved.
Applicant Information
Applicant Name

First NameLast Name
Street
City
State
Zip
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Profession
Family / Relationship Status

Other
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Education & Training
Formal Education (title, dates, location)
Professional Qualifications (certifications, association registrations)
Professional Practice Description (nature of practice, clients per week, years in practice)
Training in Anatomy and Physiology (courses, hours, specialty knowledge areas)
Health Profile
Current health concerns, symptoms, or diagnoses
Current and past medications or substances used
Major physical health history, including illnesses, accidents, falls, hospitalizations, or surgeries
History of severe emotional loss or trauma
Any mental health diagnoses or conditions
History of hospitalization, depression, or related treatment
Birth History
Your birth history and childhood details
Birth history of your children
Therapy & Support
Current therapeutic modalities you are experiencing

Other
People, creatures, places, modalities, pastimes, or interests that support you and your life
Motivation & Expectations
Why would you like to take this training?
What do you expect from this training and in what manner do you intend to use it?
Any other relevant information to support or enhance your application
Professional References
Professional Reference #1 - Name

First NameMiddle NameLast Name
Professional Reference #1 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Professional Reference #1 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Professional Reference #2 - Name

First NameMiddle NameLast Name
Professional Reference #2 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Professional Reference #2 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Program Deposit

Desposit Payment

Non-Refundable Deposit for Craniosacral Therapist Training Program

$250.00

Payment Method

Credit Card

Apple Pay

Google Pay

Acknowledgment & Signature
Due to the deep nature of this work, your personal process may come to the surface. The classes and training are not a process workshop, yet it is recognized as a natural unfoldment. In order to appropriately contain processes within class time, it is required that you be familiar with your own process and have outside resources available to support you. In signing below, you acknowledge that you have this support available and are willing to seek it. You also acknowledge that during this training that you take care of your health conditions, continue and/or seek the appropriate medical or psychological care and advice for them. The training is for professional practitioner development. It is not a replacement for them.
I have read and understand the above statement.
Add your initials to acknowledge that you have read and understand the statement above.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Click "Submit Application" below to send your application, process your deposit payment, and schedule your interview next.
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Application for Craniosacral Therapist Training Program with Peggy Reynolds

Applicant Information

Education & Training

Health Profile

Birth History

Therapy & Support

Motivation & Expectations

Professional References

Program Deposit

Desposit Payment*

Payment Method

Acknowledgment & Signature

Desposit Payment