Embodied Woman - Booking Form
- Personal Development Group for Women
Email address *
Name *
Your answer
Date of Birth *
Occupation *
Your answer
Phone number *
Your answer
All the information given in this form is fully confidential and would be treated with respect. It will be read only by the workshop facilitators who are abiding to UKCP code of ethics
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 for the facilitators to assess the needs of each participant joining the group, and also to assess if the group work is suitable for the individual (i.e. in the cases of severe PTSD and mental health issues we recommend some one-to-one therapy before joining the group).
To secure your booking please make a payment by bank transfer on the day of submitting the booking form:

The Institute of Embodied Psychotherapy
Account No: 83886786
Sort code: 20-90-74

CANCELATION POLICY: up to 1 month before the workshop - your payment will be refunded minus 20% administration fee.
No refund will be offered if less then 1 month notice.
Please indicate what rate you are paying? *
• What are you hoping to gain from this group? *
Your answer
• What is your previous experience of therapeutic work (individual/group psychotherapy, process oriented groups or any other personal development workshops): *
Your answer
• What is your previous experience of body oriented psychotherapy or any therapeutic dance and movement practice: * (Please note that no prior experience of any of the above is necessary for this group). *
Your answer
• Given the physical aspects of this experiential group, are there any medical or mobility issues that we need to be aware of? *
Your answer
• 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.) *
Your answer
• Have you ever suffered from any serious or recurrent illnesses, or had a major surgery or trauma? *
Your answer
• Are you taking any medication at the moment? *
Your answer
• In case of emergencies – who should we contact (name, relationship and contact details) *
Your answer
• How did you hear about the group? *
Your answer
• Would you like to be added to our mailing list for information about similar upcoming workshops and courses (including discounts that we offer) *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy