the evolved heart - registration

Private mentoring and supervision for Mental Health Professionals and Yoga Teachers with NeLi Martin

Personal Details

Name*

First Last

Address*

Street Address Address Line 2 City State Postcode Country

Email

Phone Number(s)

Date of Birth

Gender

Male
Female
Other

Mental Health Qualifications / Yoga Qualifications (please state what type and to what level)

Occupation and Current Job Role

Line Management and Reporting Responsibilities

Professional CPD obligations

(AHPRA / APS / AASW / OTA / Yoga Australia or other) (NeLi is not available to supervise you through the registration process as a psychologist or any other profession. However these sessions can be considered peer supervision for APS CPD requirements)

Frameworks of Practice

Your Current Therapeutic Frameworks of Practice, or Yoga Orientation; include training and workshops undertaken or given

Yoga and Meditation Practice

Please describe in detail the kind(s) of yoga and meditation practice you do, for how many years you have practiced and how frequently? (this is NOT a prerequisite)

Courses and Retreats

Please give details of any yoga / mindfulness / meditation courses or retreats that you have attended. I am looking for the name of the retreat/course, year you attended, the length of the retreat/course, who taught the course, and where it was held. If you do not recall every detail, that is fine. Please just tell me what you can recall. (This is NOT a prerequisite)

Your interest, intention and hopes in registering to work with me.

How did you hear about my work?

Contact person in case of emergency

Relationship of contact person (eg, friend, partner, parent)

Phone number(s) of contact person

Acknowledgement of Risks

The process of mentoring and supervision in the Mental Health / Yoga field covers your own psychological, spiritual and/or physical responses to your work. You may experience intense or unusual psychological, spiritual and/or physical states. I have considered the risks before choosing to acknowledge this form. I still wish to participate in the program. I accept that in ticking the box below, I will take full responsibility and liability for my own property, health and safety.

*

By ticking this box, I acknowledge these risks

*

I confirm that all the information above is correct to the best of my knowledge.

Note: all information here is kept confidential and will be seen only by NeLi Martin and her administrative team.

Payment Process

To secure your place, please complete and submit this form and make initial payment to
Commonwealth Bank Australia
(Janelle Louise) NELI MARTIN
BSB 064003
Acc 00607279
Please use your initial and surname and “TEH” in the reference

e neli@nelimartin.com
m 0420221461

Details of your investment https://nelimartin.com/the-evolved-heart/

Email

This field is for validation purposes and should be left unchanged.

the evolved heart – registration

Private mentoring and supervision for Mental Health Professionals and Yoga Teachers with NeLi Martin

Personal Details

Acknowledgement of Risks

Payment Process