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Confidential application for 50-hour Kintla Yoga Therapy® method certification for mental health practitioners (KYT-C)
If you feel uncomfortable answering any of the questions listed here, we can discuss them during the interview.
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Name
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Address
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City
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State
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Zip
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Country
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Phone (mobile)
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Phone (home)
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Email Address
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Occupation
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Date of Birth
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Emergency Contact Name & Phone Number (1)
Your answer
Emergency Contact Name & Phone Number (2)
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How did you hear about this program?
Your answer
Do you have a 200-Hr. Yoga Teacher Training (YTT) Certification?
Yes
No
When and where did you complete your 200-Hours?
Your answer
Do you have yoga teacher training beyond the 200-hr. certification? If so, please explain.
Your answer
How long have you practiced yoga?
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What styles/traditions of yoga have you practiced?
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What style/tradition do you practice now?
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Are you currently teaching yoga? If so, how often do you teach?
Your answer
What styles of yoga do you teach? How long have you been teaching?
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Have you taken any yoga therapy training programs? If so, which one(s), and are you currently practicing yoga therapy?
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Do you have training in meditation or other healing arts? If so, please explain.
Your answer
Please explain any education or training you have received in medicine and/or psychology.
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Please describe any introspective work you have done to date that you would like to share.
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Please explain any education, training and/or personal experience you may wish to share about emotional-psychological trauma.
Your answer
Are you a trauma survivor? (optional)
Yes
No
Unsure
What are your goals and objectives with this certification?
Your answer
Do you have any special interests or capabilities that may be relevant?
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How do you intend to use your KYT certification?
*
Your answer
Are you currently undergoing psychiatric treatment? If so, please explain or contact Kintla directly.
Your answer
Option 1
Do you have any concerns about your physical or mental health that may impact your participation in this program? If yes, please explain any additional support you might need from Kintla Yoga.
Your answer
Do you want to teach yoga or would this training simply be for your own edification? If no, please explain.
Your answer
DISCLOSURE AND ACCEPTANCE OF TERMS. By checking the "I accept" box below and submitting this form I hereby declare the above information is true to the best of my knowledge. I understand that misrepresentation of this information constitutes grounds for the rejection of this application, expulsion from the program and revocation of certification. In the event of rejection, expulsion, or revocation of certification, I understand that I am entitled to no refunds, credits, or adjustments.
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