Online Application Form

First Name:

Last Name:

Email:

Street:

City:

Province:

Postal Code:

Fax:

Home Phone:

Work Phone:

Cell:

Employer Name & Address:

Nature of employment including type of business, your poisition and responsibilities:

Date of Birth:

Relationship Status:

Name/age/gender of children (if applicable):

Education: (list certificated and/or degrees attained):

Interpersonal/Helping Profession Skills Training and Experience (e.g. life skills, therapy, volunteer work etc. to provide a summary of your educational, occupational, and life experience history):

As Personal Psychotherapy is key to becoming a competent psychotherapist, please mention your previous experiences in therapy (e.g. type of therapy, how many hours received, whether it was beneficial etc.):

How did you hear about The Lifespace Institute?:

How does applying to The Lifespace Institute fit in with your goals and life dream?

Desired Program:

Professional Counsellor Certificate

Please Check Off Desired Additional Certificate Program(s) if applicable:

Expressive Artist/Therapist Relationship Counsellor Lifespace Trainer

Desired Start Date:

Contact in Case of Emergency:

Phone Number:

Top