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Safety Questionnaire

Please click Start below and answer the first question, then click the Next button to move to the next question.   

As a requirement for admittance to the IFS Basics course and all courses without a prerequisite (if you have not yet filled out a Safety Questionnaire with us), you must answer every question.

When you have completed the questionnaire you will see a Restart button, which you can click if you want to go back and change any of your responses. 

When you are done with the questionnaire, scroll down to agree with the Disclaimer.  You will then move to the Registration page.

 

Click the button below to start.

Start

Question 1 of 12

Please share your name, email address, location, and phone number. 

Question 2 of 12

Which Course or Group are you registering for? (please give details - e.g. the number and month it starts for courses)

Question 3 of 12

What psychological issues are you facing now or wanting to work on?  

Question 4 of 12

How much and how frequently do you currently use drugs and alcohol?  

Question 5 of 12

Do you have any history of emotional instability?  If so, please give a brief description.

Question 6 of 12

Is there any danger that accessing pain or childhood memories could be destabilizing for you?  If so, please explain your concern.

Question 7 of 12

Have you been hospitalized for psychiatric reasons or treated with psychiatric drugs?  If so, please give a brief summary of your experience. 

Question 8 of 12

Are you currently in psychotherapy?  If so, for how long?  

Question 9 of 12

If you were in emotional difficulty, or felt like you were falling apart, where would you turn?  

Question 10 of 12

Are you currently on any psychiatric drugs?  If so, please describe.

Question 11 of 12

What previous IFS training have you had?

Question 12 of 12

By submitting this form, you are signing up for our email list. What information are you most interested in hearing about? 

(Select all that apply)
A

I am interested in one of Bonnie Weiss's courses, which include learning IFS and training in IFS for therapists.

B

I am interested in becoming a member of an Interactive IFS group with Jay Earley.

C

I am interested in professional training to lead Interactive IFS groups with Jay Earley.

Confirm and Submit