Hakomi-Informed Coaching Application

Early Registration: December 31, 2024

Final Application: February 14, 2025

Final Registration: February 28, 2025

First Name *

Last Name *

Nickname / Preferred Name

What gender pronouns do you use? *

She/Her

He/Him

They/Them

Other (share below)

Prefer not to answer

What race / ethnicity do you identify with? (check all that apply) *

Black or of African descent

East Asian descent

Latino/a/x or Hispanic

Middle Eastern or Arab descent

Native American or Alaska Native

Pacific Islander

South Asian or of Indian descent

White or of European descent

Other (share below)

Prefer not to answer

Do you identify as any of the following? (check all that apply)

Black, Indigenous, Person of Color

Immigrant or refugee

LGBTQIA+

Person with disabilities

Veteran, first responder, active military

Member of minority religious group

Please share any other important ways you identify.

Embodywise is dedicated to fostering a diverse, equitable, and inclusive learning environment. Please explore our commitments to DEI on our website.

Contact Information

Email *

Please use the same email for all Embodywise submissions and communications.

Phone

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SMS / Text Message Opt-In

I agree to receive text messages at the phone number provided above. I understand data rates apply, reply STOP to opt out.

Address *

City *

State *

Country *

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code *

Organization

Website

Emergency Contact Name *

Emergency Contact Phone *

Professional Information

Briefly describe the extent of your coaching experience, including length of practice and clientele you work with. *

Do you have any Hakomi designations? *

Trainer
Teacher
Teacher in Training
Certified Hakomi Therapist
Certified Hakomi Practitioner
None
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What is your prior experience with Hakomi? (check all that apply) *

Intro Workshop

CIIS Hakomi Course

Professional Skills Level 1

Professional Skills Level 2

Comprehensive Level 1

Comprehensive Level 2

Other (share below)

None

Are there any additional Hakomi experiences not listed above? Please provide Hakomi teachers and trainers you've studied with.

Why do you want to take this training, and how will you use it in your work? *

Embodywise and Hakomi Institute do not support or endorse any illegal use of psychedelics. Please review the position of Hakomi Institute on psychedelic assisted psychotherapy.

Participant Confirmation *

I have reviewed the link above and confirm that the knowledge and practices gained in this training will not be used to support the illegal use of psychedelics.

Learning Goals and Needs

How do you hope this training will benefit you professionally and personally? *

Is there anything you would like us to know about how we can make your learning experience most beneficial? Do you have any special needs we can accommodate? *

Are you able to make all the training dates listed? If not, please list dates and times you will be absent. *

Scholarship Form

Do you want to apply for a scholarship? *

Yes

As a nonprofit, we have a limited amount of scholarships available. We respectfully ask for your transparency in completing the scholarship questions. Our goal is to make our programs as accessible and equitable as possible while stewarding the financial health of our organization. Scholarship amounts are based on the regular registration price, not the early registration price.

Are you experiencing financial hardship?

Yes
No
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Please select all of the following that apply to your current financial situation.

Historical family and community economic injustices or disadvantages
Significant costs for care of loved ones (ie. children, parents, or other relatives)
Recent and significant unexpected expenses (ie. health, home, or legal)
High debt (ie. student, credit card, or loans)
Current salary does not meet rising cost of living
Unemployed or underemployed
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Please provide any more context on your selections above that would be helpful for us to know.

Do you primarily serve historical underserved or disadvantaged populations?

Yes
No
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Please select all of the following populations that you primarily serve.

Black, Indigenous, People of Color (BIPOC)
Migrants, asylum seekers, refugees, or immigrants LGBTQIA+
LGBTQIA+
Economically disadvantaged
Persons with disabilities
Veterans, first responders, or active military
Members of minority religious groups
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Please provide any more context on your selections above that would be helpful for us to know.

Please provide the approximate number of clients you serve each year. This will help us communicate the impact of our programs and scholarships to donors.

Please share any other extenuating circumstances we should be aware of.

Please share what tuition amount you are able to pay, keeping in mind that payment plans are available.

Full tuition is $2,500. The maximum scholarship amount available for those in greatest need is $1,000.

Application Fee and Submission

Sell Products *

Coaching: Application Fee

This fee is required to submit your application.

$75

*Payments are securely processed through Stripe.*