Karlton Terry & Team Workshops and Trainings
Workshop Information form

Please note: If you have filled out a Workshop Information Form at previous workshops of Karlton's, you need only fill in the items marked with an asterisk (*), and sign/date the form at the end. 

*Name:                                                                                        

*Address:                                                                                      

                                                                                             
         City                     State                   Zip                       Country

 *Telephone:                                  home                                 work

 *Date/Location of current workshop:                                                            

 Present occupation or profession:                                                                   

Single    Married       Living Together    Separated        Divorced    

 *Your date of birth:                                  Number of Children:               

Ages and Names of Your Children:                                                                   

 Current Licenses, Certificates, Degrees:                                                             

*A physical, emotional, or mental health concern I have is:                                                                                              

 *My purpose for coming to the workshop is:                                                          

Who referred you to the workshop?                                                                  

Are you currently in psychotherapy? If so, with whom and where

(e.g. John Barnes in New York)?                                                                         

Please indicate the number of years you have received counseling or
Psychotherapy, the orientation of your therapist(s), and the outcome(s):

Are you currently on psychological medications(s)? Please list and explain: 

Have you ever been hospitalized or medicated for mental health reasons?

 If so, please explain:                                                                            

 Has anyone in your family of origin, including yourself, or anyone in your
 ancestry been hospitalized for psychological reasons? If so, for how long? 

 Is anyone in your family of origin currently under psychiatric or
psychological care? If so, who and for how long?                                                       

What do you intend to do with techniques or approaches that you learn in  

the current workshop?                                                                          

Will you need support after the workshop? If so, clarify what sort of  

support you feel you might need:                                                                    

 *Please check the following and sign below:

          I take full responsibility for my well-being during and after the current training workshop.

          I will not hurt others, or myself nor provoke or allow others to harm me either accidentally or on purpose. I will be safe and alive, and honor the safety of others.

          I will not be violent without a contract. I will arrange for the safe expression of feeling.

          I am in good physical, emotional, and mental condition, and can participate in the current training workshop.

          I understand that if I choose to participate in regression exercises, I will be protected from harming myself and others to the best of the leader or facilitators' abilities, and that there is always risk involved in strenuous physical activity. Therefore, I accept full responsibility for making sure that I do not harm others or myself.

         I will not regress without a contract. I will not make myself too emotionally vulnerable or get into a 'child' space without arranging for safety and protection first.

          I will honor the privacy of fellow group members and the therapists by not talking about anything that takes place in group that could in any way identify another person. I also agree to deal directly with fellow group members and the leaders, and will refrain from unhealthy gossip.

         I understand that Karlton Terry recommends all persons undergoing pre- and perinatal regressions to be in psychotherapy, that Karlton Terry is not available to provide such services, and that he does not represent himself as providing such services. I understand that the current workshop was not described as group or individual psychotherapy, and is not intended or designed to offer psychotherapy. I further understand that the purpose of the workshop is educational and/or for training.

         I understand that the regularly scheduled activities of the current training workshop may bring up psychological material that requires psychiatric, psychological, or psychotherapeutic care, and I will take responsibility to schedule such care as deemed necessary by myself and/or my family and healthcare practitioner.

         I accept complete responsibility for my own personal safety on the property wherever the workshop is located.

         I have been informed that in this kind of workshop touching and holding occur as a matter of course and are considered healing and therapeutic. I agree to not touch others with sexual intent and not to invite sexual touching from others.

         I agree that I will not give feedback to another person(s) without their permission. I will always ask permission first, and I will honor the boundaries that are set. 

         I will not leave the workshop during workshop hours, with the intent of not returning, without first consulting with and/or informing Karlton Terry directly (verbally).

         I understand that Karlton Terry is not a psychologist, psychotherapist, or psychiatrist, and is not licensed to practice any of the foregoing. Karlton Terry is a pre- and perinatal educator, certified teacher of Emerson Training Seminars, has trained with Graham Farrand, Ph.D. and others. By signing below I agree to take full responsibility for my emotional, psychological and physical process, and agree to hold Karlton Terry harmless and indemnify Karlton Terry from any injury, act, liability or loss I may incur as a result of attending this workshop.

Signature:                                                      

Print Name:                                                     

Date:                                                          

Karlton Terry
303-832-1117
fax 303-832-2404
750 E 9^th Ave #207,
Denver, Colorado 80203
KTprenate2birth@gmail.com