Therapeutic Touch Invitational Mentorship Program

Deadline for receipt of applications: May 1.

Instructions: Fully answer the questions below to the best of your ability. The decision by facilitator, to accept your application to this workshop, will be influenced by this written information.

Section 1

Name:

Address:

City:

State:

Zip:

Phone (home):

Phone (work):

E-mail:

Fax:

Profession:

Licensing Body:

Section 2

Evaluate your strengths and weaknesses as related to Therapeutic Touch:

Do you practice other healing therapies? If so, which ones?:

What is your personal objective(s) in participating in the Mentorship program?:

What kind of mentoring would be most helpful to you at this time?:

Please describe any ongoing medical conditions you have (this in no way prejudices your application).:

In order to anticipate and provide for the needs of all those who attend the workshops -- patients, students, and teachers -- it is important to know if you have a psychological or physical medical condition.

List previous Therapeutic Touch workshops attended.:

Indicate instructor(s), the length of the workshop and whether it was Basic, Intermediate, or Advanced level of study.

Describe your professional background and lay health related activities::

List your extracurricular activities and interests related to Therapeutic Touch::

List two goals regarding your Therapeutic Touch practice five years from now, and how do you visualize those goals being achieve:

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Therapeutic Touch Invitational Mentorship Program