Wellness Counselor and Certification Program

Application for Admission

Name (Mr. Miss Ms Mrs.):  
Address:  
City:   State: Zip:
Phone (home):   (work):
(cell):   (fax):
Email:  
Occupation:   Company:
Age:
Marital Status: 20 		  How Long Married?:
Children?:
Where were you born and/or raised?:  
What is your native language?:  
Religous upbringing and preference now:  
Any serious accidents or illness?:   What?:
When?:
Are you under a doctor's care?:
Yes No 		  What are you under a doctor's care for?:
Are you taking any medications?: For what?:
Spare time activities:

High school you graduated from:
City and State of high school: OR, date and place high school equivalency exam was taken:
Have you ever seen a counselor?: For what?:

*Write a short essay describing your life, the adversities you have overcome and how you overcame them. Include how you envision using these counseling skills and with whom?



I am applying online and would like to pay the $100 application fee by credit card. TOTAL:
Credit Card:
   CC#
Expiration Date (XX/XX):
 
If paying by check, print out form, fill in your information and send with application fee of $100 to:
The Hawaii Wellness Institute, 3670 Kalihi Street, Honolulu, HI 96819

The statements on this application are true. I understand that if I qualify for admission, I will be expected to attend every class, to give practice sessions weekly, and to pass a written exam in order to obtain certification as a wellness counselor.

Date________________

Signature__________________________________________________

The Hawaii Wellness Institute does not discriminate on the basis of race, color, national origin, sex, religion, age or disability.


*Applying by mail: Attach typewritten essay describing your life, the adversities you have overcome and how you overcame them. Include in this essay how you envision using these counseling skills and with whom?


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