RIM® Professional Program Application Form Name of Your RIM Trainer:*Select Your InstructorDr. Deb SandellaMichael KlineLotte VesterliKine AashimeApril MooreJennifer SchaeferName of the RIM Program:* Dual RIM® & Generational Healing Certification Goodbye, Hurt & Pain Virtual or Immersive 6-Week Program Teacher Training: Project Heal Date MM slash DD slash YYYY Attach a recent photograph of yourself here:Accepted file types: jpg, gif, png, jpeg, bmp, pdf, Max. file size: 128 MB.Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Work):Phone (Cell):*Email* Web Address What is your highest level of education and course of study?What is your current profession and professional qualifications?How did you hear about The RIM® Institute:Personal Goal(s) for Attending The RIM® Institute: For personal growth and expansion To build a RIM® practice RIM® as an adjunct technique in current profession Don’t know Other OtherExpand upon your personal and professional goals for attending The RIM® Institute:What is it about RIM® that attracts you?What is your desired outcome for participating in the program?How do you plan to implement this work in your personal or professional life?What other personal transformational work have you done (please list)?What other professional training programs have you attended (include year, degrees and certifications)?Have you ever been past or presently in personal counseling or therapy?*YesNoIf Yes, why, when and what was the outcome?Name of Therapist/Psychiatrist:Phone/email:Signature for permission to contact above therapist:What is your current state of health – physical, mental and emotional? Please list any significant medical challenges:*Are there any financial, emotional, mental, physical or family challenges, mental or medical diagnoses, or anything else that might prevent your full participation in the program?Have you ever been hospitalized for mental health reasons?*YesNoAre you taking medications for psychological reasons?*YesNoIf yes, please list?Are you able to travel and attend ALL of the Program seminars?YesNoIf No, what prevents you from traveling or attending?How do you plan to finance your Program’s financial investment?Will you receive emotional support from your partner/family to attend and complete the Program?YesNowhy not?What is your greatest fear in participating in this Program? Your greatest vision?Give three reasons why you have decided that this Program should be part of your personal and professional journey. Take the ACE Survey–Adverse Childhood Experiences Study: The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the U.S. health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention. Participants were recruited to the study between 1995 and 1997 and have since been in long-term follow up for health outcomes. The study has demonstrated an association of adverse childhood experiences (ACEs) with health and social problems across the lifespan. Completion of the ACE Survey is part of your RIM application, so we can support you to have the best learning experience possible in RIM Programs. Your score is confidential and only used by the RIM staff to support you. There are 10 questions. Simply answer yes or no to each Add up the number of "YES" answers to determine your ACE score: 1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?* Yes No 2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?* Yes No 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?* Yes No 4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?* Yes No 5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?* Yes No 6. Were your parents ever separated or divorced?* Yes No 7. Was your mother or stepmother… Often or very often pushed, grabbed, slapped, or had something thrown at her? Or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?* Yes No 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?* Yes No 9. Was a household member depressed or mentally ill, or did a household member attempt suicide?* Yes No 10. Did a household member go to prison?* Yes No Your Score*What organization are you seeking continuing education credits for:* ICF Continuing Education Credits NASW Continuing Education Credits Teacher Continuing Education Credits National Board for Health & Wellness Coaching (NBHWC) National Association for Alcoholism and Drug Abuse Counselors Continuing Education Credits Other N/A Other Value* The following signature is verification that above information is accurate & true:Name*Date* MM slash DD slash YYYY **A phone interview may be required before acceptance. This field is hidden when viewing the formSubmission TypeDirectCheckoutEmail NotificationThis field is hidden when viewing the formOrder Id Δ