TRAINING PROGRAM APPLICATION FORM To which Program are you applying? (select one) Gestalt Training Program (GTP) Working With Physical Process (WWPP) Group Intervention Training Program 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 How did you hear about the training program? * Colleague E-mail Flyer Friend/Family Member GIC Faculty Member Social Media Website 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? Continuing education (CE) you are seeking * None Counselor Social Work OPA-MCE (Ohio Psychologists Only) APA (Non-Ohio Psychologists) License # If you are seeking continuing education (CE), please enter your license number. References 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 click the link below to begin the payment process. Featured A Gestalt Approach to Working with Groups and Teams, Module 2 (PROGRAM TEMPLATE) Hidden Figures: Helping couples discover underlying patterns in their communication A Gestalt Approach to Working with Groups and Teams, Module 1 Gestalt Institute Leadership Development (GILD) Writing Better: Enriching Your Writing Process Neuroscience and the Art of Gestalt: Enhancing Relational Effectiveness Men's GEW - Gestalt Experience Workshop Creative Expression: Going Deeper with Your Coaching Clients The POWER of Resistance: A Gestalt Approach Hidden Figures: Helping couples discover underlying patterns in their communication.
