Practitioner Certification Program Practitioner Certification ProgramApplication Form 1Personal Information2Assessing your Readiness3Reflection First Name* Last Name* Email* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Application and Self Assessment of Readiness for Program As we are limiting the number of certification candidates to 20 per cohort, we request that you complete the following form in order to help yourself and us assess your readiness for this intensive program. Please know that if you are not chosen to participate for this cohort, you will be refunded your $500 investment and you are welcome to apply again for future cohorts. Depending on the number of people who apply for certification, we may not be able to provide immediate feedback about your application. Please be patient with us as we will endeavor to respond to everyone in a timely manner. Date you completed the Holding Space Foundation Program (formerly the Holding Space Practitioner or Coach/Facilitator Program):* MM slash DD slash YYYY Please rate your current capacity/level of comfort with holding space for the following:Giving constructive feedback one-on-one*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Receiving constructive feedback one-on-one*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Giving constructive feedback in a group setting*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Receiving constructive feedback in a group setting*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Addressing conflict*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Self-regulating when experiencing intense emotions*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Attending to self care*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Balancing your own needs with the needs of the group*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Asking for what you need*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Identifying when you and/or another individual or the group need to pause*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Stepping into a leadership role*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Recognizing and addressing who needs to be centred in a challenging situation*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Identifying and taking ownership of your shadow, biases, and privileges*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Celebrating your victories, strengths, and accomplishments*Scale: 1 (low comfort/capacity) 2, 3, 4, 5 (high comfort/capacity) 1 2 3 4 5 Please take a few minutes to answer the following questions as succinctly as you can.Reflecting on what you learned in the foundation program and what you have learned in your own experiences, describe your current understanding of Holding Space.Give an example of how you held space for others recently.How have you held space for yourself recently?Have you walked through conflict with a person or group? What was that like for you? What were you most proud of? What did you discover to be your learning edges?What challenges do you anticipate facing being in a community where you will be asked to give and receive generative feedback?What would the value of being a Certified Holding Space Practitioner be for you in your life and work?What (if any) reservations do you have about participating in this program?
