Name

Credentials/Licensure

Email Address

Phone Number

Mailing Address

Current Profession

Years of Professional Experience

Professional Background (Select all that apply) Professional Background (Select all that apply) Mental Health Professional Allied Health Professional Life Coach Equine Professional Other

Please describe your "other" professional background

Current certifications and licensures

Brief description of your current practice/work

Tell us about yourself and your professional journey

What brings you to this program? What specifically interests you about polyvagal theory and its applications?

What are you most excited to learn from this program?

What unique perspectives, skills, or experiences will you bring that might contribute to the learning community?

Please rate your current knowledge of Polyvagal Theory Please rate your current knowledge of Polyvagal Theory No prior knowledge Basic understanding Intermediate understanding Advanced understanding

Have you attended any previous training in Polyvagal Theory? Have you attended any previous training in Polyvagal Theory? Yes No

Please describe the previous Polyvagal Training(s) you have attended

How do you currently incorporate polyvagal principles (if at all) in your professional work?

Which of the following experiential modalities (if any) do you have experience with? (Select all that apply) Which of the following experiential modalities (if any) do you have experience with? (Select all that apply) Equine/Animal-Assisted Activities Nature-Based Activities Culinary or Food-Based Activities Other Experiential Modalities

Please describe your experience with Equine/Animal-Assisted Activities

Please describe your experience with Nature-Based Activities

Please describe your experience with Culinary or Food-Based Activities

Please describe your experience with Other Experiential Modalities

How do you hope to apply what you learn in this program to your professional work?

Which experiential modalities are you most interested in exploring or deepening your practice with?

Please describe your experience working with horses

Do you have any experience working with horses? Do you have any experience working with horses? Yes No

How did you hear about this program? How did you hear about this program? Website Colleague Professional organization Social media Other

Please specify "Other"

Do you have any physical limitations or accessibility needs we should be aware of?

Professional Reference #1 Name

Professional Reference #1 Relationship

Professional Reference #1 Email

Professional Reference #1 Phone

Professional Reference #2 Name

Professional Reference #2 Relationship

Professional Reference #2 Email

Professional Reference #2 Phone

By submitting this application, I confirm that all information provided is accurate and complete. I understand that acceptance into the program is subject to review by the program directors and that the program has specific prerequisites and expectations as outlined in the program materials. By submitting this application, I confirm that all information provided is accurate and complete. I understand that acceptance into the program is subject to review by the program directors and that the program has specific prerequisites and expectations as outlined in the program materials. I acknowledge that the above statement is true