Application 
Submit this application form to be considered for the Embodied Awareness in Action™ Practitioner Training & Certification Program. 

Leif carefully reviews applications and will reach out to you with questions or to schedule an interview if she believes you are a good match for this immersive personal and professional development opportunity. 

**Leif Hallberg endeavors to keep all personal information private and confidential, and will not share any personal information with third parties.
Sign in to Google to save your progress. Learn more
Email *
Name *
Phone Number *
Address (street, city, state, country)  *
Date of Birth *
MM
/
DD
/
YYYY
Gender  *
Assuming you are accepted into this training, what payment option would work best for you?

*Payment options DO NOT include individual supervision sessions, international transfer fees, or travel, lodging, and meal expenses for the in-person workshop. 

** To secure a guaranteed spot in this training you will need to either make the payment in full (and receive the discounted rate) or make the first payment (if using the payment plan option) as soon as you have been accepted.  
 *
Cancellation Policy: The success of the Embodied Awareness in Action™ Practitioner Training is reliant upon group process, so having a consistent group is critically important. Students start this training together and no new students will be admitted once the course has begun. Thus, once a student is accepted into the program and pays the full tuition (for the discounted rate) or the first payment (for payment plans) they are expected to commit to the course in its totality. No refunds are given if a student decides not to participate in the course or is asked to leave the course for lack of participation or misconduct. Students utilizing the payment plan option are also responsible for payment of the full tuition if they should choose to drop out of the course. 
 *
Degrees and professional licenses/registrations held (list year, institution, and degree/license or registration awarded):  *
Certifications and/or additional trainings attended (list year and name of program or certification):  *
Occupation *

What drew you to the Embodied Awareness in Action™ Practitioner Training & Certification program?

 *
What personal and professional goals might you hope to achieve by attending this training? *
Briefly describe your experience with horses:   *
Briefly describe any experience you have including horses, nature, mindfulness, art, etc. in human services (i.e. therapy, coaching, education, etc.):  *
Do you have prior experience with self-directed learning? Do you consider yourself a self-directed learner? Share your thoughts/feelings on this topic. *
Speak to your comfortability and interest in self-growth and self-exploration: *
How comfortable are you in a group context? *
What do you perceive as your greatest strengths within a group context? *
What do you perceive as your greatest challenges within a group context? *
Is there any thing you are nervous or anxious about going into this experience?  *
Is there anything else you feel would be helpful for me to know about you? *
Health Information *
If you indicated you have a physical or mental health condition that might have an impact on your participation in this course, or special needs that I should be aware of, please provide a brief description of the condition. 
Do you have any allergies? *
If you answered yes, please list what allergies you have and what treatment is required: 
Emergency Contact #1 (please list the name, relationship to, and phone number of an emergency contact):  *
Emergency Contact #2 (please list the name, relationship to, and phone number of an emergency contact):  *
Liability Waiver:  I acknowledge the risks involved when working with horses. However, I feel that the possible benefits to myself are greater than the risks assumed. Intending to be legally bound, for myself and my heirs, assigns and legal representatives, I hereby forever waive and release any and all claims, whenever arising, against Leif Hallberg, M.A., LPC, LCPC and her respective representatives arising from, or relating in any way to my participation in the Embodied Awareness in Action™ Practitioner Training & Certification program. 
 *

Consent For Emergency Medical Treatment: In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in a hands-on day, zoom call, or retreat as a part of the Embodied Awareness in Action™ Practitioner Training & Certification program, I hereby authorize Leif Hallberg to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication.

 *
Photo and Media Release: I consent to and authorize the use and reproduction by Leif Hallberg of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program. *
Thank you for you interest in this powerful learning journey! I am so excited to meet the next cohort of open-hearted adventurers!! 
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
reCAPTCHA
PrivacyTerms
This form was created inside of Leif Hallberg.