Email
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary
*
(###)
###
####
Secondary
(###)
###
####
Age
Sex/gender with which you most closely identify
*
Prefer not to answer
Male
Female
Race
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White
Two or more races
Prefer not to answer
Highest Level of Education
*
High school diploma
Some college
Associate's
Bachelor's
Master's
Doctorate
Business/Organization
Position
Occupation
*
Business Owner
Coaching
Counseling
Education
Human Resources
Law
Management/Administration
Medicine
Nursing
Organizational Consulting
Psychology
Religion/Ministerial/Clergy
Social Work
Other
If other, please describe
Were you referred to the training program?
*
Yes
No
If so, by whom?
Have you taken workshops or training programs at GIC?
*
Yes
No
Other Gestalt Institutes?
*
Yes
No
Please list the titles, program sponsors/leaders and date of completion of any postgraduate or special training experiences (Gestalt or other)
Why have you chosen this program and how does it fit your needs?
*
Share highlights of your experience and accomplishments.
*
Describe any major challenges or crises that might affect your participation.
Do you have coaching experience?
*
Yes
No
How long have you been coaching?
How many clients do you coach in a year?
How many hours do you coach in a year?
If you currently coach, please enter the percentage of time spent in each of the following areas (should total 100%) (Life Coaching, Executive Coaching, Business Coaching, Leadership Coaching, Career Coaching, Health Coaching, Spiritual Coaching, Other Coaching)
Reference 1 Name
*
First Name
Last Name
Reference 1 Email
*
Reference 1 Phone
*
(###)
###
####
Reference 1 Country
Reference 2 Name
*
First Name
Last Name
Reference 2 Email
*
Reference 2 Phone
(###)
###
####
Reference 2 Country
Reference 3 Name
*
First Name
Last Name
Reference 3 Email
*
Reference 3 Phone
*
(###)
###
####
Reference 3 Country
Please share any accommodations you require (e.g., ASL interpreter, service animal, ramp-accessible parking).
Thank you for your application. Please select your workshop/training program below to begin the payment process. PLEASE NOTE applications cannot be processed without the receipt of your application fee.
TO SUBMIT YOUR APPLICATION FEE AND COMPLETE THE REGISTRATION, PLEASE CLICK THE BUTTON BELOW, "COACH CERTIFICATION PROGRAM - APPLICATION FEE" AND FOLLOW THE CHECKOUT INSTRUCTIONS.