Full Name
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Address
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City
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State
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Postal code
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Phone
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May we leave a message on your voicemail?
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Yes
No
Email
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Social Security Number
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Age
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DOB
Gender
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Male
Female
Nonbinary
Do you Identify as transfender?
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Yes
No
Education (grade/degree completed, any post secondary?)
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Current Occupation
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Name of person to alert in case of emergency
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Emergency Contact Phone Number
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Emergency Contact Address
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Emergency Contact City
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Emergency Contact State
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Emergency Contact Postal Code
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Relation to emergency contact
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Relationship Status
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Single
Married
Partnered
Separated
Divorced
Widowed
If not married, are you currently in a relationship?
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Yes
No
Children (gender, age)
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Have you had experience with altered states? Psychedelic medicines?
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Medical Illnesses, Current and Past--anything that might affect your participation as a Facilitator--or enhance it? Have you had Covid 19?
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Have you had previous psychological care or counseling?
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Yes
No
Have you ever been hospitalized for a psychological difficulty?
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Yes
No
Have you ever had feelings or thoughts that you didn’t want to live?
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Yes
No
Have you ever been convicted of a felony?
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Yes
No
Are you currently experiencing overwhelming sadness, grief, or depression?
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Yes
No
Are you currently experiencing anxiety, or panic attacks?
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Yes
No
How many days per week do you drink alcohol?
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How many drinks per night?
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How often do you binge drink (4-5 drinks within a couple hours)?
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Have you ever had a dependency on alcohol or recreational drugs?
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Yes
No
Have you ever or do you now have a history of prescription drug dependency or abuse?
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Yes
No
In your own words, what is the nature of your interest in becoming a Facilitator? Feel free to describe this in as much detail as you wish to give us a sense of this. What do you consider some of your strengths? Weaknesses?
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What is your personal experience with trauma and its aftermath: violence—physical, sexual, emotional; abuse; natural occurrences; etc.?
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What is your experience with trauma and its aftermath in others? In what format(s) have you assisted/treated those who suffer with trauma?
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Are you able to conduct Sharing Groups by being timely, with a stable internet connection, a private setting in which others cannot hear the conversation outside of the group, and possess adequate audio and visual equipment to support connection through eye contact and clear voice?
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Yes
No
Do you agree to maintaining the confidentiality of each group member and what is shared within the group container, and only share this information with your Consultant/Supervisor, or if you feel someone would harm themselves or someone else?
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Yes
No
Do you hereby certify to the best of your knowledge that all information provided is true and correct.?
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Yes
No