RADICAL ALIVENESS/CORE ENERGETICS
INSTITUTE OF SOUTHERN CALIFORNIA

2010-2011 TRAINING PROGRAM APPLICATION

*Name:
*Date of Birth:
*Address:
*City:
*State:
*Zip:
Work Phone:
Home Phone:
Cell Phone:
*E-mail:
*Applying For
* = required fields
* Job History:
* Education & Training History:
* Therapeutic History: (have you been in some form of therapy, when and for how long?)
* Pertinent Medical Conditions:

* Medications: (please indicate all medications you are currently on and what conditions they are for both physical and mental)
* What is attracting you to this program and what are you hoping to get out of it?
* What are the strengths that you feel you will bring to this program?
* What do you see as places that you need help to grow?
* How might these places get in the way of your work in this program and what is your intention for working on these places?
* Is there anything else that feels important for me to know about you?

Please submit and then click below to pay $50 non-refundable administrative fee. Or check may be sent to:

Ann Bradney
Radical Aliveness Institute
836 Venezia Ave.
Venice, CA  90291

or pay online