Level 2 Recycle Application for Level 2 Graduates

LEVEL 2 Recycle Application

Name:*
First Last
Email:*
Enter Email Confirm Email
What year did you graduate Level 2?*
Permanent Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Area Code + Phone:*
Gender Pronouns:
Occupation:*
Date of Birth:*
Country of Birth:*
Country of Citizenship:*
Emergency Contact Name:*
Emergency Contact Phone:*
Emergency Contact Email:*
Please upload a photo of yourself (for identification purposes only):*
Why do you want to recycle Level 2?*
Briefly describe why you feel drawn to retake Level 2 at this time and what you hope to gain from recycling this training.
Physical and Mental Health Survey
Tamalpa Institute is a school for movement-based expressive arts therapy. It is necessary that we assess the physical, mental, emotional issues that might affect a student in the training program. In order to ensure that we are able to maintain a healthy supportive learning environment for all our students, we have included some specific questions regarding mental and physical health, below. Please note that confidentiality will be maintained to the fullest extent. The institute does not discriminate against anyone on the basis of any actual or perceived disability. The purpose of this questionnaire is to assist you and us in deciding whether our program is right for you, and whether you may require any extra assistance to fully participate in and benefit from our program. While the program can be very therapeutic, it may be beyond the scope of the training program to provide specifically for the mental health needs of an individual student. If a student is likely to need 1:1 therapeutic support, we aim to recognize this in advance and discuss with the student how to structure this support. It is our policy that faculty members do not act as therapists for individual students, since this is a dual role. We have a local resource list that includes mental health professionals. Please answer the following questions to help us with our assessment:
Please list all physical health conditions for which you are currently undergoing treatment. Please list the names and contact info of your healthcare providers (if relevant)*
Do you have any allergies?*
Please list medication that you are currently taking. Please make sure that you have enough medication to last during the program that you are enrolled for.*
Please list any physical conditions that you have received treatment for in the past that could potentially recur. Please include injuries as well as any conditions that are chronic and could possibly recur in the future. Please especially note any condition that could be exacerbated by an intensive movement-therapy training program.*
Have you been hospitalized for mental health reasons? If so, please give dates and duration of hospitalization, and the diagnosis.*
Are you currently taking medication for mental health reasons? Please list:*
Have you been prescribed psychoactive medication? Please list:*
Have you experienced any of the following? *severe depression or anxiety *manic episodes *suicidal thoughts *paranoia*
Have you been diagnosed with an eating disorder?*
If you should need therapeutic support, what resources do you currently have available?*
Is there anything else you want to let us know about your mental /emotional health that would help us to ensure your successful journey through our training program.*
Untitled
Untitled
Untitled
Untitled
Untitled
Untitled
Untitled
Untitled
Name
This field is for validation purposes and should be left unchanged.

LEVEL 2 Recycle Application

Physical and Mental Health Survey