Embodied Approach to Working with Parts
ASSESSMENT AND BOOKING FORM 
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Email *
Confidentiality:
All the information given in this form is fully confidential and would be treated with respect. It will be read by the workshop facilitators at the Institute of Embodied Psychotherapy - who are abiding to UK AHPP code of ethics

Data protection:

Any electronic communication will be with your consent and you can withdraw your consent at any time. If we experience any data breaches we will inform you as soon as possible. 

Any records about you (such as personal details on our booking forms) are kept secure and subject to the general data protection regulations. We will keep those record for the duration of your involvement with IEP. You are entitled to have your data destroyed at any point.  

Name and Surname *
Date of Birth *
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Occupation *
Address:  *
Phone number *
Safety assessment
Given the therapeutic aspect of this workshop we need some personal information about each participant who will join the group. 

The following questionnaire is a for the facilitators to assess the needs of each participant that is joining the group and also to assess if this kind of therapeutic work won't be suitable for someone (i.e. in some cases of severe PTSD, mental health or physical illness – which might make this group unsuitable for you). 

Please note that this is advanced workshop – and in some previous personal experience of working with 'Parts' (not just professional CPD) is needed in order to join this group.

Please fill in this assessment form - so that we could assess if this group would be suitable for you and please do not make a payment before we email you to offer you a place.  If we have some questions or concerns we will contact you to discuss. 


Payment
Please proceed with the payment once you get a conformation email from us offering you a place. 
Please save the bank details attached below. 

To secure your booking you will need to pay the fee by bank transfer within one week of receiving our offer to join this workshop. 

The Institute of Embodied Psychotherapy
Account No: 30354597
Sort code: 23-14-70 

Please note that this is a very popular workshop and bookings are on first-come first-serve bases. 
So we won't be able to hold your place if we do not receive the payment within one week.

CANCELATION POLICY: 
up to 6 weeks before the workshop - your payment will be refunded minus 20% administration fee.
No refund will be offered if less than 6 weeks notice.

Please note - the 6-week cancellation policy also applies to transferring onto another course or workshop: for example if you are unable to make the date that you booked for and you cancel less than 6 weeks, it is not possible to transfer your booking onto a future workshop.

Please indicate what rate you are paying? *
• Date of the workshop you are booking: *
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• Your professional qualifications: *
When and where did you qualify?   *
• What  are you hoping to gain from this experiential workshop/group? *
• What is your previous personal experience of therapy and 'Parts' work (individual/group psychotherapy, process oriented groups or any other related personal development workshops): *
•   What is your previous professional experience of 'Parts' work (IFS Parts work or body oriented Parts work: CPD, groups etc)  : *
• Any previous experience of embodied psychotherapy or any other body-oriented or dance-movement therapeutic practice:  *
• Given the physical aspects of this experiential group, are there any medical or mobility issues that we need to be aware of? *
• Given the emotional aspects of this therapeutic group, are there any mental health issues or emotional problems? (Including history of depression, anxiety or mood disorders, trauma or PTSD, addictions etc.)   *
• Have you ever suffered from any serious or recurrent illnesses, or had a major surgery or accident/trauma? *
• Are you taking any medication at the moment? *
• In case of emergencies – who should we contact (please give their name, relationship and contact details) *
• How did you hear about the group? *

• What attracted you to this Embodied Parts group/workshop?

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• What are you hoping to get from this therapeutic workshop?

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• Have you ever done any other Embodied Psychotherapy workshops/groups (run by Katarina or at the Institute of Embodied Psychotherapy)? If so which ones and when?

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• Have you ever done any similar therapeutic groups in the past? If so please name any significant ones that made an impact on you

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• Do you have any concerns or reservations about working in a group (working experientially)? 

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• Do you have any concerns or reservations about working with embodiment, movement, meditation and guided visualisations? Any concerns or reservations about working with your body (somatic approach to therapy)? 

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• Anything else that you’d like the facilitators to know about you prior to the start of the group... or anything else that we should be aware of (for your own safety)?

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• Would you like to be added to Institute of Embodied Psychotherapy mailing list for information about similar upcoming workshops and courses (including discounts that we offer) *
• By sending this form I agree with the Institute of Embodied Psychotherapy Terms and Conditions (PLEASE READ THEM BEFORE SIGNING THIS FORM): https://www.embodiedpsychotherapy.org.uk/terms-and-conditions  *
A copy of your responses will be emailed to the address you provided.
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