CST Diplomate Certification Program

Todays Date

Name (First, Last) *

Date of birth *

IAHP Student Number

Your student number appears on your Certificate of Attendance that you receive after completing a class, with the hours attended. If you are unable to locate your student number please contact Shane Hill.

Phone Number (office or mobile) *

Email Address *

Professional Information

Other Profession

Professional Experiance (last 10 years) - Location, specialty, title *

Professional affiliations (last 10 years) *

Group name and your function in the group

Continuing education seminars/courses outside of the Upledger Institute - Location, date, organiser. *

Client/Patient population summery *

What kind of things are you predominantly treating in your clinic.

UI Preceptorships and or Mentoring Program *

Please list your involvement in any guidance you have received from practitioners/lecturers involved with UI.

What are you personal goals for your career in CST *

Please list your goals for CST within the next five years.

Has any malpractice claim or suit ever been brought against you? *

Yes

No

Malpractice Information *

Please detail the specifics of the malpractice suit filed against you.

Have you ever been the subject of disciplinary action, reprimand, admission refusal or suspension before any court or administrative agency? *

Yes

No

Please outline the details of any discipline you have experienced as a result of an investigation of your professional conduct at the local, state or national level.

Disciplinary Information *

Please detail the specifics of the malpractice suit filed against you.

Declaration

As a practitioner using therapies taught through Upledger Institute International, you are expected to adhere to the highest professional standards. This section outlines your commitment and declaration to the service of your clients.

I pledge my commitment to provide quality therapy, to seek educational opportunities to enhance my therapeutic skills, to respect each client's right to privacy. *

Yes

No

I will provide quality therapy without discrimination and accept the responsibility to do no harm to the physical, mental and emotional well-being of self, client and associates.

I pledge (once acquired) to maintain the UI Certification. *

Yes

No

Each certified therapist maintains UI Certification with a minimum of 24 hours of UI-approved continuing education every four years. This may be in the form of UI CST courses (participating or assisting), mentor programs, symposiums, research conferences or preceptorships. Certified therapists must adhere to the Code of Conduct of the UI Certification Ethics Committee at all times.

I acknowledge this information is true and accurate. *

Yes

No

I hereby apply to the CranioSacral Therapy Technique Certification Program and will abide by the rules and regulations thereof. I further acknowledge that this certification, upon awarded, is not intended to be used as a hands-on licence.

Explaination

If you have answered No to any of the declaration questions, please fully explain your position.

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CST Diplomate Certification Program

Professional Information

Declaration

Service Conditions

Service Info

BUSINESS INFORMATION