In addition to the regular Southern Connecticut State University application, which is required for Masters and Sixth Year degree students, individuals desiring Gestalt training are asked to list three references along with this application.

Name: __________________________________ Date:_______________

Home address: _______________________________________________

Home phone #:___________________ Work phone #: ________________

Employer name/address: ________________________________________
___________________________________________________________

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DUTIES AND RESPONSIBILITIES:
Your participation in person growth groups and/or personal therapy is indicative of your willingness to work on your personal concerns and important in our assessing the suitability of the program for you. Therefore, it is hoped that the following questions will be answered as completely as possible.

1. What outstanding experiences have you participated in recently?
   
   
   
   
   
   
   
   
   
   
   
   
   
   
2. Describe an important influence in your development as a professional?
   
   
   
   
   
   
   
   
   
   
   
   
   
   
3. If there have been significant changes n your life situation in the past year, please describe them.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
4. Write a brief statement regarding your reasons for pursuing Gestalt training and your expectations of the program.
   
   
   
   
   
   
   
   
   
   
   
   
   
   

List three references. Please contact them and give permission for them to answer our inquiry. If you are currently or have recently been in therapy we would prefer that you list your therapist as one of your references. Be sure to give complete addresses.

Name of reference, address, and telephone number.

1.______________________________________________________________

2.______________________________________________________________

3.______________________________________________________________

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