Application for the Somatic Awakening® Practitioner Program

This questionnaire is designed to provide us with valuable information, which will be useful in our work together and will help determine whether the SAPP program is appropriate for and of benefit to you. This information will be held confidential and will only be used in the application process.

Name

First Last

Today's Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Home Phone

Cell Phone

How did you hear about Somatic Awakening® and/or Sophia Healing Academy?

Briefly describe any previous involvement with Somatic Awakening® and/or Sophia Healing Academy?

Please give a brief description of what interests you about this work and why this program is calling to you at this time in your life?

Are you interested in attending SAPP as a practitioner, non-practitioner, or are you undecided? Feel free to go into detail as desired.

Please describe any major events or themes that stand out for you in your life that you want to bring awareness and healing in this program?

Were you ever physically, sexually, or emotionally abused in your childhood or adult life? If so, please briefly describe.*

Briefly describe your current home life? Do you have a partner, husband/wife? Children? If so, how many and what ages. Looking at your home life do you feel that there is anything that would make it difficult for you to complete this program?*

Briefly describe your work history, current occupation, and any pertinent financial issues you are going through.*

What kinds of spiritual work are you, or have you been, involved with in the past? Do you have an on-going practice? If so, please describe.*

Have you had experiences of spiritual awakening, profound synchronicity, or other life-changing spiritual experiences in your life? If so, please explain.*

Is it relatively easy for you to connect to your intuition, emotions, energy, and in generally making contact with your inner reality? Or, is this difficult for you? Please explain.*

Briefly describe any current and/or previous experience with therapies (psychotherapy, psychiatric treatment, hospitalization, counseling, body-oriented therapies, somatic therapies, energy medicine therapies, or any other types of growth work.)*

Are you currently taking any medications connected to emotional issues or pain medication, such as anti-depressants, anti-anxiety medication, benzodiazepines, opioids, etc.? If so, please describe.*

Briefly describe your relationship to alcohol, drugs and food. Have you, or has anyone in your life, considered your relationship to these substances as a problem?*

Have you ever been seriously depressed, were falling apart, had a “dark night of the soul” experience, or suffered major anxiety? If so, what happened and when did this occur?*

Have you ever been diagnosed with a mental illness? If so, is it actively present in your life now?*

Have you ever tried to harm yourself or considered suicide? If so, when?*

Are you currently dealing with any significant health problems? If so, please briefly describe.*

Have you had any major injuries or surgery? If so, what were these and how old were you?*

Are there any other traumas you have walked through that you have not mentioned above that you feel are still affecting your life currently? If so, please describe.*

What are the central issues in your life at this time?*

Is there anything else that you would like to comment on that you feel is important for us to know about regarding this program and your life?*