Application

This class teaches you how to use Internal Family Systems, a powerful form of psychotherapy. This class is not psychotherapy, nor is it intended to replace psychotherapy or health care. The exercises you will do in this class may touch deep places inside you that can cause psychological, emotional, physical, or behavioral reactions. For some people, these reactions may be hard to deal with.

IFS is a very safe and respectful form of inner work, but for a few people this class may not provide the kind of individual attention and structure needed to feel balanced and safe while working on deep personal issues.

This survey is designed to help you think through how you will have the best experience in this class and give me a sense that you've made an informed decision and are ready for this work. If you would like to discuss whether the class is safe for you, feel free to email or call Keith at keith@keithmillercounseling.com or 202-629-1949 ext 2.

The information shared on this form will not be viewed by anyone other than Keith Miller and is confidential.

Class Dates*

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What professional discipline do you practice with clients? (i.e. social work, psychology, psychiatrist, clinical counselor, etc.) *

What experiences have you had with Internal Family Systems Therapy? (i.e. IFS therapy, attendance at an IFS workshop or training or educational materials) *

What psychological issues are you facing now or want to parts of you would you like to work on? *

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

Do you have any history of emotional instability? Please explain.*

Is there any danger that accessing emotional pain or childhood memories could be destabilizing for you?*

YesNo

If you experienced emotional difficulty or felt like you were falling apart, what steps would you take to regain stability?*

Are you currently in psychotherapy? For how long?*

I understand that the IFS IFS Level I Prep Course taught by Keith Miller is not psychotherapy or health care and is not intended to replace psychotherapy or health care.

I understand that even though the course content teaches a psychotherapy method, the exercises are intended to teach me skills for my personal growth. Exercises may involve accessing sensitive psychological material, and I declare that I have the psychological stability to handle whatever may come up.

I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Keith Miller or Keith Miller Counseling, LLC responsible for any pain or damages that may occur.

A check indicates I agree to the above disclaimer and my typed full name below is equivalent to my signature.

Signature: Please type your full name*

NEXT STEPS: Wthin 48 hours after completing this form you'll receive confirmation of your application and an invitation to enroll. At that time payment is due and you'll be directed to an online payment portal.

Thanks for your interest in learning IFS with me. This is amazing and fun work and I look forward to meeting you soon!

Keith

Application

Disclaimer