ADVANCED HOLISTIC COUNSELING™ & COACHING CERTIFICATION COURSE APPLICATION 2024-2025

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ADVANCED HOLISTIC COUNSELING™ & COACHING CERTIFICATION COURSE APPLICATION 2024-2025

POSITIVE ENERGY
Holistic Counseling & Institute
597 Middle Road Bayport, NY 11705

institute@positivecounselingli.com
www.positivecounselingli.com

PRE-PROGRAM PREP: July 15 – Sept. 28, 2024
COURSE START DATE: Sept. 28, 2024
COURSE END DATE: June 8, 2025

Today's Date *

YYYY

Name *

Date of Birth *

YYYY

Address *

Email Address *

Phone Number *

Website *

Facebook *

Instagram *

Linkedin *

Current Profession *

Current Employer *

Employment Address *

Employment Phone Number *

This Section Is For Applicants Who Work In The Field of Mental Health

Tell us about yourself (check all that apply) *

I am still earning my Masters in a Mental Health-Related Field (MSW, MHC, MFT, etc)

I have not earned my License at a Masters level yet (LMSW, LMHC Limited Permit, LMFT)

I am in a Graduate program in a Mental Health-Related Field and am seeking an internship

I have earned my Masters & LMSW/Limited LMHC/LMFT/PsyD/NP/MD/or equivalent but need to earn my “Clinical Hours”

I have earned my LCSW/LMHC/LMFT/PsyD/NP/MD/equivalent but want to build more efficient, effective, and transformative Clinical skills

I want to learn a system to add the best Holistic Skills to my therapy sessions

I want to represent the AHC Holistic “brand” and be a part of a community of specialized therapists who maintain high standards, provide & receive Clinical support, and offer modern, cutting-edge results to clients

I want to do more in my Psychotherapy sessions than just listen compassionately. I want to teach my clients the skills to transform so that they have them for a lifetime.

I want to personally transform into my most aligned and powerful self by using the AHC Skills on myself

I already have my own Private Practice

I work for someone else’s Private Practice

I work for an agency or school

I want to own my own Private Practice in the future

I work Full-time providing Psychotherapy to clients in Private Practice

I work Part-Time providing Psychotherapy to clients in Private Practice

I am able to make a full-time income and feel prosperous in my current Psychotherapy Career

I love to learn and I consider myself to be a “coachable” person who is open, curious, and willing to change

I want to learn the skills to have a Self-Pay, Six-Figure thriving Holistic Psychotherapy Practice

At the end of the AHC Certification, I would be interested in taking an additional course to enable me to create a “Self-Pay, Six-Figure thriving Holistic Psychotherapy Practice Full of Motivated Clients”

Required

This Section Is For Healers, Coaches, or People Interested In Becoming Coaches

Tell us about yourself (check all that apply) *

I am certified or trained in one or more healing modalities (Reiki, yoga, energy work, etc.)

I have been trained in or taken courses related to coaching.

I am new to becoming a healer or coach.

I would like to learn the skills of Advanced Holistic Counseling™ & Coaching so that I can expand my career or develop a coaching practice.

I want to personally transform into my most aligned and powerful self by using the AHC Skills on myself

I love to learn and I consider myself to be a “coachable” person who is open, curious, and willing to change

I work full time providing healing or coaching services.

I work part time providing healing or coaching services.

Required

How did you hear about the Advanced Holistic Counseling™ & Coaching Certification Program?
*

What about the AHC Certification Program appeals to you? *

What do you hope to learn or experience by taking the AHC Certification Program? *

What is your vision for the next 2-5 years in your career? *

Personal Statement: Tell us more about you! What would make you a great fit for this program? Share some information about your personal character, qualities, or interests. Whatever you would like us to know, please share it here:
*

Do you desire to work as a therapist in our private practice at Positive Energy Holistic Counseling & Institute or are you already involved in a private practice?
(Some therapists may be asked to join our team during or after the AHC Certification Training)
*

Professional and Educational Information

Please type "n/a" in cases where the question is not-applicable.

Professional Licenses: Type of License, State License Granted In, Year Granted (i.e. LMSW, NY, 2015)
*

Undergraduate Education: Name of College; years attended, date of graduation, degree received *

Postgraduate Education: (M.D.; Ph.D. or Psy.D. in clinical psychology; MSW, Ph.D., or D.S.W. in social work) Name of universities; area of study; dates attended; date of graduation, degree received *

Internships, Externships, Residencies, Placements, Fellowships, and other Postgraduate Training: Names of institutions; dates attended; brief descriptions of duties and activities; full names of supervisors *

Teaching and Supervisory Experience: Name of institutions; courses taught; students taught; dates; full names of department heads *

Continuing Education Trainings, Courses, or Certifications (Please only list the more substantial CEU courses with higher # credits you have earned or that represent your interests)

(i.e. Trauma- Informed CBT, CPI Online Training, 12 hours/credits, Nov 2015)

Holistic, Alternative, or Complementary Training, Education, or Certificates/Certifications (i.e. Reiki Reiki II Certification, The Reiki Institute, Sept-Nov 2015) *

Holistic or Alternative Interests or Practices (i.e. Yoga Nidra 3/wk, walking 4x/week, daily 20 min meditation practice, etc.)
*

Psychotherapy: Are you currently receiving psychotherapy, psychoanalysis, or counseling services? Have you received these services in the past? Describe your experience as a client: *

Clinical Supervision: Are you currently receiving Clinical Supervision? Have you received Clinical Supervision in the past? What have your experiences been like with these services? *

Professional References

(Please provide two professional references, or one professional reference and one personal reference)

Name (1) *

Phone Number or Email Address (1) *

Relationship with Reference (1) *

Name (2) *

Phone Number or Email Address (2)
*

Relationship with Reference (2) *

Legal Issues

Do you have any legal issues pending? *

Yes

If yes, please explain *

Have you been convicted of a crime? *

Yes

If yes, please explain *

Have you had your professional license suspended/revoked at any time OR do you have any legal issues regarding your profession at this time? *

Yes

If yes, please explain *

What's the next step?

1) Thank you for your interest and application! All applications will receive a response from us.

2) Eligible applicants will be sent a link to schedule an Interview and Discovery Call.

3) Please check off and then sign the following:
*

All of the information in this Application is known to be true by me.

I hereby give permission to Positive Energy Holistic Counseling & Institute (PEHCI) to make inquiries about me, in connection with this application, to any and all of the institutions, their officers, and supervisors referred to in this application. (Additional references may be submitted by the applicant.) Positive Energy Holistic Counseling& Institute admits students of any race, religion, national origin, ethnic origin, age, gender, disability, marital status or sexual orientation to all the rights, privileges, programs, and activities generally accorded or made available to students at the Institute. It does not discriminate on the basis of race, religion, national origin, ethnic origin, age, gender, disability, marital status or sexual orientation in regards to the administration of its educational policies, admissions policies, scholarship and loan programs, and other Institute administered programs. In the event of my acceptance as a student in training at PEHCI, I hereby agree not to conduct Advanced Holistic Counseling™ & Coaching (AHC) treatment and not to represent myself as a practitioner of AHC until I am authorized to do so by the PEHCI.

Applicants from any of the disciplines listed in this application must demonstrate suitable professional and personal readiness for AHC training. The Admissions Committee will assess the applicant’s education and evidence of excellence in clinical work commensurate with the level of training as well as personal factors which are important in determining the appropriateness of AHC training. All applicants will be considered without regard to national and ethnic origin, religion, age, gender, marital status, disability or sexual orientation. AHC Certification and Graduation from PEHCI requires the completion of the course of study undertaken.

Required

Today's Date *

YYYY

Name

(this also serves as your signature for this application)

4) Please verify all of the above information is correct, and click submit. Thank you!

Positive Energy Holistic Counseling and Institute
597 Middle Rd Bayport NY 11705
institute@positivecounselingli.com

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