Application

/Application
Application 2018-01-15T19:30:28+00:00

Please send the completed application as a Word or PDF file to judithajohnson@mac.com.

Application

Contact Information
Name:
Birthdate:
City, State & Zip:
Phone, Skype, etc:
E-mail:

Basic Résumé
Occupation
Education
Family

Previous Experience with PNE or Other Healing Modalities
Which practitioners have you worked with?
How many sessions have you had?
Which other types of therapies have you been involved with, as a client or practitioner?
Are you living some version of a regenerative lifestyle? (Please answer in detail.)

Medical Issues
Do you have any active addictions that you’re struggling with?

Are you taking anti-depressants or other prescription medications?

Are you seeing a counselor or mental health professional on a regular basis?

Goals
What are your goals for the Practitioner Training Course?

Why do you want to pursue this training?

Is there any information that is important for us to know about you that could affect your participation in this training?

Judith Johnson, (919) 245-8082 (home), (828) 773-3445 (cell), judithajohnson@mac.com

Sieglinde Hieronymus, +49 8368 266 434, sieglinde.hieronymus@gmx.de