Spiritual Sexual Educator Certification Application

Name*

First NameLast Name

What name or nickname to you want to be called?*

If you identify as non-binary, what are your preferred pronouns?

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Date of birth*

MonthDayYear

Relationship status*

Occupation*

Emergency Contact*

First NameLast Name

Emergency Contact relationship to you*

Emergency Contact Phone (cell preferred)*

Do you have a website? If so, please list the URL(s)*

How did you hear about the Empowered Feminine Leadership Training?*

Do you have (or suspect you have) any history of mental health issues, mental illness, or suicidal tendencies? Have you been diagnosed with any mental imbalances? (please describe, including any diagnoses)*

Do you have (or suspect you have) a history of sexual trauma? *

Please list any chronic illnesses, injuries, or recent surgeries.*

What is your level of familiarity with the chakra system?*

	1	2	3	4	5	6	7	8	9	10

1 is Not very familiar, 10 is An expert

What is your level of personal experience with sexual healing and awakening work (workshops, trainings, and/or private sessions)?*

	1	2	3	4	5	6	7	8	9	10

1 is No experience, 10 is Lots of experience

What is your current intention for taking this training, knowing that it might change?*

If you answer "For my own personal healing journey," you may skip the next two questions if desired.

Tell us about your education, both classic and alternative. List any certifications you've earned or trainings you have completed.*

If you are planning to become a Certified Spiritual Sexual Educator, what is your vision for your future as a facilitator of sexual healing? How do you imagine using this Certification to enhance or expand your current offerings?

Do you have any special needs/allergies around food? If so, please specify. We will do our best to accommodate your needs during the live training segments.*

Which payment option would you like to choose?*

Is there anything you would like to share with us at this time, or anything else you would like us to know?

By submitting this form, I understand that my application will be considered by the staff and if approved, I will be expected to make my tuition deposit. I affirm that I am prepared to make this commitment.

I further understand that no part of this training should be construed as a substitute for medical examination, diagnosis, or treatment. I understand that the facilitators are not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the training should be construed as such.

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the facilitators updated as to any changes in my profile and understand that there shall be no liability on the part of the facilitators for any reason whatsoever.

By typing my name in this box, I affirm that I have read, understood, and agreed to all of the above, and have been truthful and accurate with my answers. I request that my application be considered for acceptance into the Empowered Feminine Leadership Training. *

Application for Empowered Feminine Leadership Training Module 1