WEBINAR EVALUATION FORM for CEs - SOMATIC-BASED THERAPIES FOR TRAUMA Name* First Last Date MM slash DD slash YYYY PhoneEmail* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website (if applicable) Your area of expertise, professional interests and focus:*A. Based on the content of the course, I acquired knowledge of:1. Practical somatic psychotherapy skies* Strongly Agree Agree Neutral Disagree Strongly Disagree 2. Neurological theories of trauma* Strongly Agree Agree Neutral Disagree Strongly Disagree 3. Tools for stabilization* Strongly Agree Agree Neutral Disagree Strongly Disagree 4. Pathways for learning more about somatic psychotherapy* Strongly Agree Agree Neutral Disagree Strongly Disagree B. Course Content and Learning Experience:1. Content was appropriate for LMFT, LCSW LPCC, and LEP training:* Strongly Agree Agree Neutral Disagree Strongly Disagree 2. Information could be applied to my practice.* Strongly Agree Agree Neutral Disagree Strongly Disagree 3. Teaching methods were effective.* Strongly Agree Agree Neutral Disagree Strongly Disagree 4. Information was current and accurate.* Strongly Agree Agree Neutral Disagree Strongly Disagree C. Instructor, Nicholas Barth, MA, LMFT1. Dr. Southern knew the subject matter.* Strongly Agree Agree Neutral Disagree Strongly Disagree 2. Dr. Southern presented the material well and answered questions effectively.* Strongly Agree Agree Neutral Disagree Strongly Disagree 3. Dr. Southern was responsive to questions that were posted or that were to be addressed in this presentation.* Strongly Agree Agree Neutral Disagree Strongly Disagree 4. Dr. Southern utilized course-appropriate technology to support learning.* Strongly Agree Agree Neutral Disagree Strongly Disagree D. Materials and Documents Provided1. Instructional materials were suitable and useful.* Strongly Agree Agree Neutral Disagree Strongly Disagree 2. Articles provided were of interest and relevant.* Strongly Agree Agree Neutral Disagree Strongly Disagree 3. The Hyperseuxal Behavior Inventory is a useful questionnaire for my practice and/or learning.* Strongly Agree Agree Neutral Disagree Strongly Disagree E. Open-ended QuestionsE-1. What was your overall impression of the course. What went well?*E-2. What could be improved? What suggestions might you have?*E-3. What topics and presenters would you like to see at future Harmony Place presentations?*E-4. Additional comments or requests:
