Heal Your Life® Training Application

Name

Name you want on your name-tag for the training

Name you want on your certificate

City

Province or State

Zip or Postal Code

Country

Home Phone

Cell Number

Email

We use a Facebook private group for some of the follow-up after the training. If you are currently on FB, we would like to 'friend’ you now. What is your FB name?

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

How did you hear about us?
Web searchI Can Do It conferenceHay House websiteLocal magazineOther

If you selected 'Local Magazine' or 'Other' from above, can you please specify?

Briefly describe your experience with the work of Louise Hay. How has it helped you personally?

What type of healing work have you done previously (i.e., inner child work)?

Are you certified or licensed in some type of individual work (like hypnotherapy or aromatherapy or Reiki)? This is not a requirement, but having a practice of some kind already can help you with marketing the Heal Your Life workshops.

Self-assessment: What are your strengths (i.e., intuitive, compassionate, creative, experience leading groups)? How would you like to grow?

List 8 adjectives that describe your childhood.

Briefly describe any challenge in your life right now (i.e., health, career, relationship). How are you working with it?

Are you currently in therapy or have you been in therapy during the last 5 years? If yes, please explain.

Are you on any medications? If yes, please list them.

What experience have you had leading groups? (While not required, it is helpful.)

Do you want a single bedroom?
Yes, I want a separate single room.No, I do NOT want a separate single room.

What sex do you identify with?
FemaleMale

Do you have any special dietary needs? For example, allergies, vegetarian, vegan, etc.

Do you have any special needs for a physical challenge? If yes, please explain.

Do you smoke? (The hotel inside is non-smoking.)
Yes, I do smoke.No, I do not.