Life Design Detailed Information

LIFE DESIGN COURSE - Detailed Information

September 10- 13, 2015

Location: Los Angeles, CA

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

*Required

First Name*

Last Name*

Name I like to be called*

(First name for name tag)

Phone Number*

Area CodePhone Number

E-mail*

Birthdate*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Who referred me to Spectrum?*

Skype Handle

Relationship Status *

Level of Education Completed*

Degrees Held

If any

Other Workshops*

PERSONAL ASSESSMENT

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

With whom, if anyone, do you live with? (Please include name and relationship to you)*

Briefly describe your religious/spiritual views and practices, both past and current.*

Briefly describe any military service*

Briefly describe your educational background education and your feelings about it*

Briefly describe your present occupation, work or job, and your feelings about what you are doing*

Briefly describe the three events in your life that most influenced the way you see yourself and the world*

How would a person that knows you well describe you?*

What is your present state of health?*

Identify any health problems and current treatments, including prescription drugs currently being taken

What areas of your life that you are dissatisfied with, if any?

Be specific

Describe your physical appearance. What do you look like?*

If the LIFE DESIGN course were completely successful, how would things be different for you? (Be specific)

A) Immediately

B) In 5 years

Describe your vision for yourself, family and community. (Be specific)

What, if anything, might stop you from realizing your vision? (Please be open and honest)

REQUIREMENTS FOR PARTICIPATING

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 therapy within the last six months.

3. You have been prescribed within the last six months or are currently taking lithium, a major tranquilizer or antidepressant medication.

If any of these conditions apply to you, you must request an email of a PDF copy of this form, and bring it to your therapist or prescribing physician, have him/her read the entire form, including the "Notice to Professional Counselor" section, discuss the advisability of your participation, and if he/she agrees there are no therapeutic contradictions, have him/her sign the form.

In order to complete your registration in the Spectrum Life Design Education courses, please complete the following and return this form prior to the course.

BY TYPING YOUR NAME IN THE BOX BELOW, you hereby acknowledge and attest that you have thoroughly and carefully read the information contained herein, that you understand it and agree to it, that you have answered all questions truthfully, and that you have fulfilled the requirements for participating.

Name

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 in this form pack 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".

Are you currently in therapy for psychological difficulties or problems? If so, describe.

Exclude marital, vocational, and pastoral counseling

If you have been in psychological therapy, give the approximate start and end dates of for all therapy you have had

Have you ever been hospitalized for psychiatric care or mental disorder? When?

Have you ever had prescribed, or are you currently taking, lithium, thorazine, stelazine, haldol, or any other major tranquilizer or antidepressant medication? If so, describe, and for what condition.

Have you ever had a nervous breakdown? If so, describe

Please List any other medical issues below

This includes both physical and emotional/mental health issues, conditions, treatments, therapies and medications you are receiving (please be specific)

Emergency Contact Information

In the above box, please provide the NAME, RELATIONSHIP, and PHONE NUMBER of TWO Emergency Contacts who Spectrum may contact during the training, in case of emergency

NOTICE TO PROFESSIONAL COUNSELOR

PARTICIPANT PLEASE NOTE: THE FOLLOWING ONLY APPLIES IF YOU ANSWERED YES TO ANY OF THE HEALTH INFORMATION QUESTIONS ABOVE. IF YOU ANSWERED YES **YOU MUST REQUEST AN EMAIL OF A PDF OF THIS FORM, AND YOU MUST HAVE YOUR COUNSELOR / PSYCHIATRIST / PSYCHOLOGIST / PRESCRIBING PHYSICIAN SIGN AND DATE THE FORM, AND THE ORIGINAL SIGNED FORM MUST BE RETURNED TO S.L.D.E.L.A. PRIOR TO YOUR PARTICIPATION IN THE LIFE DESIGN COURSE.

IF YOU ANSWERED NO TO ALL HEALTH INFORMATION QUESTIONS LISTED ABOVE, YOU MAY TYPE N/A IN THE BOX BELOW, AND HIT SUBMIT.

Dear Counselor:

We are pleased that your client/patient is interested in participating in Spectrum Life Design Education courses and we have recommended that he or she discuss this with you. If you are not already familiar with the Spectrum Life Design Education courses, please contact Spectrum Life Design Education at (818) 395-7023.

We are a professional seminar corporation offering experiential educational programs focused on having successful results in life. We believe that those who benefit most from participating in our courses are people whose lives are already working well, or fairly well, but who want more out of life in terms of their daily experience with a particular emphasis on relationship with self, relationship with others, career, money and health. Our programs focus on becoming more self- aware and self-accepting, and provide an opportunity for the student to examine his/her beliefs, values, and ways of behaving that may limit the experience of himself/herself and others. It offers tools, techniques and an action plan that supports people to explore, expand and enhance the quality of their lives and the results they are producing.

The nature of our programs is such that a student’s feelings and emotions are likely to come into play as they begin the process of self-examination. Therefore, it may not be appropriate for individuals who have a tentative hold on reality to participate.

We would appreciate your reviewing the disclosure information contained in the online form at: https://secure.jotform.us/form/42782157493160 and then discussing with your client/patient the appropriateness of his/her participation in the Spectrum Life Design Education courses. If you both agree that there are no therapeutic contradictions to this, please sign this form. Signing this form does not imply responsibility on your part, but rather confirms that you and your client/patient have considered the matter carefully. We do not wish to interfere with your therapeutic relationship, and we feel it is important for you and your client/patient to determine the appropriateness of his/her participation.