Saturday Art Therapy Fall Workshop General Information Form (Adults)

The art therapy 10-week workshop for adults is a practicum experience for graduate art therapy students, supervised by Deb Duranczyk, A.T.R. and other faculty members who are registered art therapists.

WHEN: Ten Saturdays, FALL semester:

SEPTEMBER 19-NOVEMBER 21, 2020

10:00 to 11:30 a.m.

(or scheduled times)

Fields with asterisks (*) are required.

Adult Information

First name *

Last name *

Email *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Phone number *

Age *

Problem or topic you would like to address in art therapy? *

Special skills/interests *

Are you taking medication? *

Yes

If you answered yes to the above for medication, please list what kind. *

What other information can you share about yourself that would help us plan sessions?

If seeing another therapist, permission to contact therapist *

Yes

What is your preferred method of therapy? *

Additional preferences for sessions?

I understand that I and/or my art work made during the art therapy sessions may be photographed or
videotaped for educational purposes. I will not be identified by name during this process.

Participant consent (print name to accept the above conditions) *

WAYNE STATE UNIVERSITY, COLLEGE OF EDUCATION ART THERAPY PROGRAM RELEASE AND HOLD HARMLESS AGREEMENT

In consideration of being allowed to participate in the Art Therapy Program conducted by the Wayne State University College of Education, the undersigned hereby expressly stipulates and agrees to release, discharge, indemnify and forever hold harmless Wayne State University, its assigns, agents, officers, Board of Governors, servants, and employees from any and all actions, claims, liabilities, damages, losses or injuries of any nature whatsoever now existing or which may hereafter be sustained in connection with his/her participation in any and all activities of the Art Therapy Program at Wayne State University.

This release extends, applies to, covers, and includes all unknown, unforeseen, unanticipated and unsuspected injuries, damages, losses, and/or liabilities, and the consequences thereof, as well as those now disclosed and known to exist. The provisions of any state, federal, local, or territorial law or statute providing in substance that releases shall not extend to claims, demands, injuries, or damages which are unknown or unsuspected at the time to the person executing such release, are expressly waived.

Participant consent (print name to accept the above conditions) *

Witness name (print name to accept the above conditions) *