Please complete all information.

How did you learn about the program?
Metta Flyer Metta Website Email Workshop
Metta Graduate Advertisement (where)
Other (describe):

Personal Contact Information

Affiliated Organization Information (if applicable)

Employment/Education

Full Time Part Time Other (describe):
Degree/Certification (MD, RN, PhD, MFT, etc):
Specialty:
Current professional title:
Years in professional practice:

End-of-Life Care/Counseling Experience

Do you currently work or volunteer in End-of-Life Care?
Yes
No

How long?

In what setting:
Hospice
Hospital
Home care
Other
Describe (frequency, place, role):


Please list, briefly, the type and dates of any training you have received in psychotherapy, coaching, spiritual direction, communications training, or other counseling modalities:

Spiritual Tradition/Inner Work

Do you currently have what you would describe as a "spiritual path"?
Yes No
How would you name it?
Years of practice in this tradition?

Do you have a contemplative or meditation practice?
Yes No
Please name your specific spiritual practice(s) and frequency (i.e. church one a week, daily chanting, one hour daily meditation)

If you participate in spiritual courses or retreats, please describe what type, how often, and what duration?

Do you currently work with a teacher or spiritual director?
Yes No
Who?
How long?
Are you currently or have you ever been a client in psychotherapy, counseling or other one to one growth work?
Yes No
If yes, please describe (duration, type, etc.)

Health Concerns

(If you prefer to discuss this by phone, please let us know.)
Do you have any significant physical health concerns or medical conditions that could impact your participation?
Yes No
If Yes, please describe:


Do you have, or do have you ever had, any mental health concerns such as depression, anxiety, addictions, or other psychiatric conditions?
Yes No
If yes, please describe, including treatment received (therapy, medications etc.)

How Do You Plan To Apply Your Training?

Briefly describe how you will utilize the training:

In Your Professional/Volunteer Work? ( i.e. private practice, healthcare setting, educational institution, community organization)


In Your Personal Life? (i.e. family caregiver, spiritual development, educational training)

Commitment

Do you anticipate anything that may interfere with your commitment to the program? (This commitment requires: attendance at all four residential extended weekends and the two 8-day residential intensives, regular phone consultations and 150 hours client support and field visits in your local community) Yes No
If Yes, please describe:

References

Professional Reference

Personal Reference

Application Essay

Please answer all of the following questions with brief thoughtful responses. We encourage you speak truthfully, from the heart, in a straightforward way rather than being concerned about creating a particular impression.

Section I
Experience with the dying

In what role or capacity do you serve the dying? What has been the most challenging aspect of this work? What motivates your end-of-life care work? How has this work served you or changed you? Briefly describe your most significant experience with death. If you have a way you would prefer to die, please describe it. What are your two unanswered questions about death? (Please be specific and use a minimum of 250 words to answer.)

Section 2
Spiritual Practice/Inner Work

Briefly describe how your spiritual path and practices impact your work, and is expressed or integrated into your end-of-life care work. What do you think is the most important spiritual practice for one who is dying? List your familiarity/experience with other spiritual traditions. How would you describe yourself as a participant in experiential group process? How would you describe yourself in terms of where you are in your psychological development and/or spiritual journey? (Please be specific and use a minimum of 250 words to answer.)

Section 3
Application of the Training

Why do you want to take this training, and why at this moment in your life? Briefly outline a specific plan of how you will utilize this training in your work or local community (include any collaborative arrangements you plan to develop, educational programs or new services you intend to offer). If you have published any articles, taught any courses, facilitated groups, please list them. If you could modify your professional practice (no holds barred) what would you be doing? (Please be specific and use a minimum of 250 words to answer.)