Mental Health Client Rights Statement

The Nine Month Self Mastery Program Student Application
	First Name
	Last Name
	Street Address
	City
	State
	Zip Code
	Home Phone
	Work Phone
	Email Address
	Date of Birth
I am interested in taking this program: for personal growth for expanding my professional skills Both
Please note your highest academic training level:
Please list additional personal growth training you’ve experienced:
Are you actively practicing a spiritual path at this time?
Are you currently or have you ever been in ongoing counseling or psychotherapy? Yes No
Are you currently under the care of a psychiatrist? Yes No
Using a medicine for mental health and balance? Yes No
Which one?
What are your passions?
What do you consider to be your greatest strength?
What do you consider to be your greatest challenge?
Are you aware of specific forgiveness issues you want to work on?
What gifts do you bring to a group learning situation?
What concerns do you need addressed in order to feel comfortable in a group?
Do you have other thoughts about why this program is just right for you now?
How did you hear about this program?