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Application for West Valley Counseling Center Life in Transition Workshops
Your Name (*)

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Age (*)


Home Address (*)

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Email address (*)

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City (*)

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State (*)

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Zip (*)

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Primary Phone # (*)

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Secondary Phone #

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Dates of workshop you wish to attend (*)

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Prior Workshops Attended


Occupation


Current Medications


Have you ever been hospitalized for psychiatric treatment? (*)


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How did you find out about this workshop?


Do you have any food allergies / special needs?

(We are limited in our ability to accommodate special needs, but we would like to discuss these with you.)

Do you have a therapist? (*)


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If yes, is he/she supportive of your attending? (*)


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Please write the name, address, and telephone number of your therapist:

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Reason for attending:
What losses/issues, current and past, bring you to this workshop?

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WAIVER: I understand my participation in this program, externalization and other related activities, is voluntary. It may involve my emotions in a manner which might subject me to emotional distress. I agree to accept such risks and assume the responsibility of emotional distress and/ or other effects thereof. Further, I release West Valley Counseling Center and Sharon Burnett, PhD, MFT and other staff from all claims made by me or on behalf of me (or my estate) by reasons of illness or damages arising from attendance or participation in the workshops and /or related activities. This release includes the waiver of any responsibility by the above named individuals and/or groups also in the case of negligence.

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There will be a minimum of 15 and maximum of 24 participants per workshop.

To hold your space, print out all 3 pages and mail your completed application to:

West Valley Counseling Center 19634 Ventura Blvd. #212 Tarzana, CA 91356

Please register early as the workshop will fill up fast. For questions, please contact Sharon Burnett at sharon@westvalleycounseling.org or 818-758-9450. A follow-up letter will indicate your acceptance and confirmation to this workshop, as well as suggestions of what to bring.


I, Please let us know your name. , request and authorize Sharon Burnett PhD, MFT to speak to my therapist,
Please let us know your name. Please let us know your name. about my participation in the Grief, Loss, and Growth Workshop on
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My therapist's office address: (*)

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This process, meaning both the group format used in West Valley Counseling Center Grief, Loss, and Growth Workshops, and the individual externalization process, is not for everyone. Over the years, we have personally observed that this workshop, and the externalization of feelings technique, has been a helpful tool for many people. We’ve received many letters, and heard from many therapists, about the life changing experiences of participants. We continue to use this technique, from time to time, with our own grief work, as well. However, intense emotional processing can leave some individuals feeling “raw” and unstable. We do not recommend this process for individuals who have been diagnosed as personality disordered, “Borderline” or “Bi-Polar”, unless their therapists are knowledgeable about potential “highs” and “lows” that might result. All participants must be 21 years of age, or older.




"If you want to see the past... touch a rock
If you want to see the present... touch a flower
If you want to see the future... touch a life."
Anonymous

West Valley Counseling Center
19634 Ventura Blvd. Suite 212 Tarzana, CA 91356

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