* First Name Last Name Email * Phone * Country (###) ### #### Nationality * Why do you want to take this training? * Do you identify yourself with your physical body? Male or Female * Yes No Do you have experience in Self-Development? * Yes No Are you currently being treated, or have you ever been treated, for any mental health conditions such as PTSD, psychosis, chronic anxiety, bipolar disorder, or sleep disorders that required medication or hospitalization? * Yes No If yes, please provide more details about your treatment for these mental health condition. Are you currently taking or have you been prescribed any psychiatric medications? Yes No If yes, please list the names of the medications and what they are for, such as blood pressure, seizures, or asthma. Thank you! Amaterra Training Forminfo@agapiapostolopoulou.com
