New Student Application Name * First Name Last Name Date of Birth * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Are you interested in the online or in-person training program? * What is your interest in the Gestalt Institute of the Rockies? * What do you hope to gain from this training? * Are you currently a practicing therapist, counselor, counseling graduate student or coahc? Or have you been in the last 2 years? What is your current work? * Please list any earned academic degrees and/or coaching certificates (major studied, where they are from, dates) * Please list other post-graduate training programs you have completed. * Do you have any physical or personal needs we should be aware of in order to support your learning? * Is there anything else you want us to know? * The above information is true and complete to the best of my knowledge I understand that this application does not constitute a contract of any kind and does not indicate acceptance into the program. Should the Institute enroll me and I attend the modules, I may terminate such enrollment at any time and understand that the Institute will retain all monies paid thus far. Once your application is reviewed, someonf from the Gestalt Institute will contact you for a brief phone or video interview. Thank you for your application! Printed signature confirming that you understand the above information * Thank you for submitting the New Student Application.