Life Design Detailed Information

Life Design Detailed Information

Life Design Detailed Form. Simple Form for Life Design Contains Personal Assessment, Requirements for Participating, and Health Information. Form Preview
  • LIFE DESIGN COURSE - Detailed Information

    January 25-28, 2018

    Location: TBA

    Please fill out the information on this form. All personal information will be held in the strictest of confidence.

    *Required

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  • PERSONAL ASSESSMENT 

    PLEASE ANSWER ALL QUESTIONS COMPLETELY.  IF THE QUESTION DOES NOT APPLY, WRITE "N/A"

  • HEALTH INFORMATION

    Answer the following questions honestly and completely by responding with a yes or no. When a question is not applicable, write "N/A" in the space.


    Please be aware that this information is not intended to be used by Spectrum Life Design Education for purposes of screening. Spectrum Life Design Education programs are experiential, educational programs; they are neither psychotherapy nor medical therapy. Spectrum Life Design Education does not and cannot screen its students. Only you can decide what is right for you, and the information here is provided to assist you in making that decision.


    In the Spectrum Life Design courses, you will be invited to examine your life and various issues regarding your life. You should be aware that if any of the issues have sadness or difficult feelings and emotions attached to them in the normal course of your life, it is likely that these same feelings and emotions will emerge in the Spectrum courses. You must decide whether this is something you can handle at this time. Your willingness to experience these feelings and emotions honestly, and then let go of them, can open the way to a more joyful experience of living. The choice to do so, however, and the degree of your participation in the process, rests with you alone.


    The information requested here is meant to enable Spectrum Life Design Education to better support you during the course. It is not possible for Spectrum Life Design Education to predict any student’s experience. If during the course you find yourself feeling uncomfortable notify the staff immediately. In addition, please answer the following questions and be completely truthful. If not applicable, please write "N/A".

  • REQUIREMENTS FOR PARTICIPATION

    If you have any physical problems that may make it difficult for you to participate in the Spectrum Life Design Education courses, it is recommended that you discuss this with your physician to determine the appropriateness of your participation.


    You MUST consult with a professional counselor, therapist, or physician and obtain a signed statement that there are no therapeutic contradictions to your participating in the Spectrum Life Design Education courses if any of the following conditions apply:

    1. You have been hospitalized for a psychiatric or psychological disorder within the last five years.

    2. You are currently in therapy for psychological difficulties or problems or have stopped this therapy within the last six months.

    3. You have been prescribed within the last six months or are currently taking any major tranquilizer or antidepressant medication such as Lithium, Thorazine, Stelazine or Haldol.

    If any of these conditions apply to you, you must request a copy of this online form and a copy of the "Notice to Professional Counselor" letter from Spectrum Life Design Education. This online form and letter must be presented to your therapist or prescribing physician to have him/her read the form and the "Notice to Professional Counselor" letter in its entirety and discuss the advisability of your participation. If he/she agrees there are no therapeutic contradictions, have the letter be signed and dated by all parties.


    In order to participate in the Spectrum Life Design Education courses, we must receive the signed forms prior to the start of your course.

  • EMERGENCY CONTACT INFORMATION: Please provide the name, relationship, and phone number of TWO (2) emergency contacts who Spectrum may contact during the training, in case of of an emergency.

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