Expression of Interest

Welcome!

Thank-you for taking the time to complete this Expression of Interest form regarding this workshop - "Protection and Support Against Psychological Injury, Moral Injury, Burnout and Vicarious Trauma".

You can find information about this, and other workshops, by visiting www.healingphase.com.au.

Please carefully read and complete the relevant sections of this form. 
Rest assured the information you provide will remain confidential.
I will respond to your submission of this form within 2 business days, with an email or text message.

I am looking forward to connecting with you and answering any questions you may have.

Wishing you all the best.
 
Warmest regards.
Nick Valentine

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* 1. Date 

Date

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* 2. Are you submitting an expression of interest on behalf of you (i.e., personal), your team / employer, or both?

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* 3. Full Name

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* 4. Date of Birth

Date

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* 5. Gender Identity

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* 6. Cultural Identity

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* 7. Are you of Aboriginal or Torres Straight Island origin?

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* 8. Relevant Address (Personal or Business)

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* 9. Relevant Email Address (Personal or Business)

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* 10. Relevant Phone (Personal or Business)

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* 11. Preferred Contact

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* 12. Employer

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* 13. Role / Title

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* 14. Which workshop date(s) and location are you interested in?

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* 15. How did you hear about my services?

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* 16. Have you or your employer ever participated in a workshop by Healing Phase in the past?

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* 17. Please provide detail of your level of knowledge and / or experience on these topics.

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* 18. Please list any questions you have, or anything else that you want me to know.

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