Practitioner Program Application

Transform Your Practice & Deepen Your Impact

Thank you for your interest in the Temple Somatics Practitioner Program (TSPP). Please complete this application to help us better understand your background, goals, and readiness for the program. Your responses will remain confidential.

First Name *

Last Name *

Name you prefer to be called *

Email *

Phone *

Age *

Address *

City *

State *

Country *

Postal code *

Personal & Professional Background

What is your current occupation *

Experience in Bodywork, Somatics, or Healing Modalities: Briefly describe your training and experience. If none, please share relevant background that may contribute to your participation in this program. *

Personal Growth Work or Healing Journey: What forms of personal growth work, healing, or therapy have you engaged in? Feel free to include any relevant modalities, certifications, or practices. *

Do you have any experience or history with emotional or physical trauma that you'd like us to be aware of? While sharing your trauma history is optional, understanding any past experiences can help us provide a safe and supportive environment during the program. We invite you to share what feels comfortable for you. *

Are you currently receiving support for any trauma-related issues (e.g., therapy, counseling)? This helps us ensure you have the necessary support during the program if any emotional or trauma-related experiences arise. Please share as much as you’re comfortable with. *

Program Interest

Why do you want to join the Temple Somatics Practitioner Program? What draws you to this program? How do you envision it contributing to your life or practice? *

What do you hope to learn or achieve through this program? *

Program Commitment

Can you commit to attending all virtual sessions? YES / NO / OTHER... Please explain. *

Will you attend the in person retreat? YES / NO / OTHER... Please explain. *

Do you have any concerns about time or availability for this program? If Yes, please share more dtails *

Additional Information

Do you have any specific questions or needs regarding the program? *

Anything else you'd like us to know? *

Confidentiality and Privacy Statement

We are committed to protecting your privacy and handling your personal information with the utmost care and confidentiality. By completing this application for the Temple Somatics Practitioner Program (TSPP), you agree to the following. Please review each item carefully and check the box to confirm your understanding. *

Data Usage: The information you provide in this application, including any sensitive personal or trauma-related data, will be used solely for the purpose of evaluating your suitability for the Temple Somatics Practitioner Program.

Confidentiality: Your personal information will be kept confidential and will not be shared with anyone outside of our evaluation team except as required by law. All individuals involved in reviewing applications are bound by confidentiality agreements to ensure your privacy.

Data Security: We take your privacy seriously. Access to your personal information is restricted solely to Triambika. We implement reasonable security measures to protect your information from unauthorized access, use, or disclose.

Sensitive Information: We understand that some of the information shared, especially around your personal and trauma history, is sensitive. You are not required to provide any information you are comfortable sharing, and we will handle any details you do provide with care and respect

Data Retention: Your information will be stored for the duration of the program selection process and, if you are accepted, for the duration of your participation in the program. After the program ends, your data will be securely deleted unless you provide consent for further retention.

Your Consent: By submitting this application, you consent to the collection, use, and processing of your personal data as outlined in this statement. You also understand that participation in the program may involve discussions of sensitive personal topics and appropriate confidentiality will be maintained throughout.

Your Rights: You have the right to request access to, correction of, or deletion of your personal information t any time. If you wish to exercise any of your rights, please contact us.

Consent

Please confirm that you have read and agree to the terms of the Confidentiality and Privacy Statement: *

Agree

Today's Date *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Practitioner Program Application

Transform Your Practice & Deepen Your Impact

Thank you for your interest in the Temple Somatics Practitioner Program (TSPP). Please complete this application to help us better understand your background, goals, and readiness for the program. Your responses will remain confidential.

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