Emerald Heart School of Enlightenment : Application Form for Training

Emerald Heart School of Enlightenment

Please complete all fields. Enter details below.

Name:
Address:
Country:
Your Email
Your Phone no:
Your Date of Birth
Brief history of previous energy work or training, if any:
Current Type of Practice: (if applicable)
Years in Practice:
How did you hear of the Emerald Heart?
Have you worked with an Emerald Heart Practitioner?	Yes No
If so, who and when?
Please tell us if you have suffered from any of the following at any time:
diagnosed mental disorder or other mental/emotional health issues?	Yes No
suicidal tendencies?	Yes No
heart problems? (including wearing a pacemaker)	Yes No
alcohol or drug dependency?	Yes No
any other serious physical condition?	Yes No
Are you currently taking any medication? (or been prescribed medication which you have not yet taken)	Yes No
Are you currently pregnant?	Yes No
If you have a disability, or special needs, for which we would need to be aware of for attending training please give details: