New Student Rosen Method Bodywork Registration FormYour answers to the registration form questions are confidential and will only be seen by teachers and staff. Name * First Name Last Name For which bodywork intensive/workshop are you registering? * Email * Phone * (###) ### #### Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Name of emergency contact * First Name Last Name Emergency contact's relationship to you * Emergency contact's phone number * (###) ### #### How did you first learn about Rosen Method? * When? Where? Which teachers? Have you received Rosen Method bodywork sessions? If so, how many? Name the practitioner. * Have you received any other forms of bodywork? Please specify. * Have you studied other forms of movement/dance? Please specify. * Do you have any experience with meditation? * Have you completed any human potential training or attended any self-awareness programs? Specify: * What is your profession? * What degrees and/or licenses do you hold? * Are you certified by a state approved massage school? * What is your purpose in taking this Rosen Method workshop/intensive training? * Have you ever been in psychotherapy? If so, when? * What brought you to psychotherapy? * If you have never been to psychotherapy, please write N/A. Are you currently in psychotherapy? * If yes, please advise your therapist that you are going to be attending a Rosen Method Intensive. Have you ever been hospitalized for psychiatric care or mental illness? * Or, has this ever been recommended to you by a mental health professional? Have you ever seriously considered or attempted suicide? If so, how many times? How long ago? * If yes to the above question, what help did you receive? Do you feel suicidal now? * Have you ever been addicted to drugs or alcohol? * Have you ever been in a recovery program? If so, please describe: * What is your family situation? (Married/partnered? Children - ages?) * What support do you have in your life? (Friends, work, etc.) * Please evaluate your present emotional state. * What are your current medications? * Is there anything we should know about your physical health (illnesses, injuries, accidents)? * Is there anything else you would like us to know about you? When being addressed, what pronouns do you prefer? * She/Her He/Him They/Them Any of the above She/They He/They Other (please specify in box above) Please sign and date this registration form. * Your digital signature confirms that you have completed this form accurately and honestly, and that you have reviewed our cancellation and refund policies. Date of signature * MM DD YYYY Would you like to receive information about future Rosen Method Open Center events? * Yes No Thank you! Please refer to the RMOC website for our cancellation/refund policy.Attendance is required from the beginning to the end of the intensive.
