Name
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First Name
Last Name
Phone
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Email Address
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Emergency Contact
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This is required in case something happens to you during a Zoom call or you disclose to me a serious plan to harm yourself or other people. This information will never be used for any other purpose.
What inspires you to take this course?
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IMPORTANT: During this course, difficult emotions and memories are likely to come up. Though you will be given tools to work with this and encouraged to always move at your own pace - and even skip sessions that might be too much for you. It is strongly encouraged that you be in weekly psychotherapy if taking this course. If you have a history of severe mental illness, psychiatric hospitalizations, or are currently taking prescribed medications for a psychological issue, being in the care of a therapist is REQUIRED FOR THIS COURSE. I want to make sure you are safe and supported in doing this work. Please TYPE "YES" below to acknowledge you have read this and agree to these terms.
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What psychological and/or behavioral issues are you facing now or wanting to work on?
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Do you have any history of emotional instability, self-harm, suicide attempts, or psychiatric hospitalizations? Please explain.
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If you were in emotional difficulty or felt like you were falling apart, where would you turn?
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Are you currently seeing a licensed psychotherapist?
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Please read the disclosure below and type your initials if you agree with these terms.
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I understand that Ralph's online courses are not psychotherapy. Even though they teach psychotherapeutic methodologies, they are intended to teach me skills I can use for my personal growth. I understand that the practices in this course can elicit difficult and painful emotional material and that the nature of Ralph's course is to offer me skills to relate to that material directly instead of avoiding it. I declare that I have the psychological stability to handle whatever may come up. I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Ralph De La Rosa responsible for any pain or damages that may occur.
Please type your name in place of your signature:
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