Training

Training Application Form

APPLICATION FOR THE HELLERWORK PRACTITIONER TRAINING

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Instructions:

1. Please type this application, or enter on a computer. Fill in all the blanks, and answer all the questions completely.
2. Attach a full-length photo. Return this application along with a $200.00 selection fee and a $1500.00 deposit (to reserve a space in the training) to: Northwest Hellerwork Ltd, #40 - 1120 Summit Avenue, Victoria, B.C. CANADA V8T 2P7. (250) 382-9931, or
Don St. John, Ph.D., 3210 NE 167th Street, Lake Forest Park, Washington, 98155, USA, (206) 368-8145.

$100.00 of the deposit is a non-refundable application fee.

The information on this application is confidential and will not be revealed outside the Hellerwork training staff.

• PERSONAL INFORMATION
Name:
Address: (City/St/Prov/Postal Code/Zip Code)
Country:
Phone: Length of time at current residence?
Age /Birth date / Birth time / Birth location?
Ht. /Wt. / Marital status / Have you been married before?
For how long? Do you have children? How many? What ages?
If you have children who live with you, what are your plans for their care during intensives?

Occupation Employed by
Business address City/St/Prov/Zip
Country
Business phone ( ) How long at this position?
Please provide a brief employment history.

• EDUCATIONAL EXPERIENCE
High school graduate? yes_____ no_____ Years in college
College attended
Undergraduate degree(s)
Graduate degree(s)
Other educational experience (courses, trainings, etc.)

• LICENSING/CERTIFICATION
List currently held licenses or credentials (M.D., Attorney, P.T., O.T., CPA, Pilot, Teacher, etc.)
Since
Since
Since

• FINANCIAL INFORMATION
Monthly income Net worth (assets less liabilities)
Monthly expenses
Please present your plan for paying for your Hellerwork Training and for covering your living expenses during the times of the training and your first few months in private practice? What are your options should this plan not work.? Please be very detailed.

1. Why do you want to be a Hellerwork Practitioner?

2. What do you consider your three major accomplishments in life?

3. As a Hellerwork Practitioner you will be an independent business person solely responsible for the success of your business, including promotion, scheduling, marketing, money management, etc. Please discuss: how prepared you feel to undertake the responsibility for your own business, what prior experience you have to call upon, and what do you consider your weaknesses and strengths in this regard. Please rate your overall readiness to deal with this responsibility on a 1 to 10 scale: ___ (where 10 = outstanding readiness).

4. As a Hellerwork Practitioner you may be working with people of all ages who have a variety of backgrounds, personal histories, and personal problems. People may experience a wide variety of emotional or physical reactions during sessions including anger, sadness, joy, and physical or emotional discomfort. It is important that practitioners possess the ability, desire, and emotional maturity to work intimately with others. Please discuss what life experience and personal traits you have that indicate your ability to handle these types of situations. Include any concerns that you have in this area. Please rate your overall readiness in this area on a 1 to 10 scale: ___

5. As a Hellerwork Practitioner you will be physically working with people's bodies. Please discuss your experience with and your feelings about working with people in this way.

6. As a Hellerwork Practitioner you will be using your body in an active way. Describe your body, what lessons you have learned from your body, and how you feel it will support your work as a Practitioner. Please rate your overall physical readiness on a scale of 1 to 10: ___

7. What body work or movement work have you personally experienced, and what were the results?

8. Although there is growing acceptance for this type of work, as Hellerwork Practitioners we are still very much "pioneers" so to speak. This demands self generated initiative, confidence, and most of all commitment. Discuss what this means to you and why you feel you will be successful. Please rate your readiness in this area on a 1 to 10 scale:

9. Undertaking a major career change often requires the support of others in one's life. Discuss how your close family and friends feel about your choice and what support you can expect from them.

10. What might be your greatest potential strengths and weaknesses as a future practitioner?

11. Please discuss any concerns, questions or considerations you have about becoming a Practitioner.

12. Have you read and do you clearly understand all of the provisions of the licensing agreement with Hellerwork Inc.? Are you in agreement with the principles involved in this contract?

13. Imagine that it is ten years from now. Write a brief "curriculum vitae" outlining what you have accomplished in the last ten years. Please hand write this answer. Please use the back of the page also if you need more space.

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