The Polyvagal Practice™ Neuroception – Outer Environment Sign-up Form The Polyvagal Practice FormΔ Step 1 of 2 - Information 50% InformationClass Rules First NameLast NameEmailPhone/MobileUnited States+1United Kingdom+44Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850North Macedonia (Северна Македонија)+389Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358How did you hear about The Polyvagal Practice? Michael Westgate's office Michaelwestgate.com Instagram Facebook Dr.Rockwell/Polyvagal Sangha Group OtherPlease specify:How familiar are you with the fundamentals of the Polyvagal Theory?- Select -Not muchSomewhat familiarVery familiarI'm an expert!What books, articles, and other materials about Polyvagal Theory have you read? (Please check all that applies.) Book - The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe, by Steven W. Porges Article - Neuroception a Subconscious System for Detecting Threats and Safety, by Steven W. Porges Book - The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation, by Deb Dana OtherPlease specify:For the best possible experience, I highly recommend being familiar with the basic terms and ideas that make up Polyvagal Therapy. Please read this vocabulary glossary before the class starts. This vocabulary glossary will be sent to you via email after signing up for the class.- Select -I AgreeI Do Not AgreeWhat brings you to The Polyvagal Practice?What are you hoping to get from participating in The Polyvagal Practice?Next The Polyvagal Practice™ Rules and Guidelines Following the Polyvagal Theory principles requires us to be aware of how we affect each other when we are together on ZOOM. Below are guidelines for how to maintain a safe and supportive environment for everyone in The Polyvagal Practice™. Please note: I don't recommend participating in The Polyvagal Practice™ to anyone who is currently suffering from acute PTSD symptoms. Some of the images and exercises presented in the course could be activating. Be Mindful of Yourself and Others: In The Polyvagal Practice™, we aim to create an environment that fosters feelings of safety for everyone in the course. Therefore, please be mindful of how your behavior and attitude affect other people. Make Yourself Visible to Other Members: Please make your face visible and your voice audible to other participants during the ZOOM class. Good lighting that shows your face clearly and a good headset or microphone are best. Refrain from using virtual backgrounds as those can be triggering and distracting to others. Recommended light: Video Conference Lighting Kit Also, would you please set your profile picture in our private Facebook group as a portrait photo of yourself (clear and friendly). It would be ideal if your Facebook name somewhat matches your name in the ZOOM class. That way, we will most likely recognize each other and feel more comfortable engaging. Remove Distractions: Put your phone aside, turn off notifications, close the door and let anyone else in the house know not to disturb you during the ZOOM class. Please do not join the live ZOOM class from your car, a café, or a public area. Eliminate any background noise or visual distractions that others would see behind you. Please be as presentable as you would be if you were coming to this class in person. Wear comfortable clothing that will allow you to move and breathe freely. Respect Everyone's Privacy: Being part of The Polyvagal Practice™ requires mutual trust. Authentic, expressive discussions will add more value for everyone, but we also must be sensitive and considerate. Please respect that all personal details shared in the group stay in the group. The full recording of the class will be available only to members of The Polyvagal Practice™. E-Course Disclaimer Please read the E-Course Disclaimer Technical considerations: I recommended that you participate using a laptop or desktop computer. iPad and iPhones may lack the control options for you to download material etc. I recommend downloading Adobe Acrobat Reader. Check that your device has a working speaker, microphone, and camera. I recommend using a computer with a dual-core processor and 8.0 GB RAM (or higher). For a better user experience, consider downloading the ZOOM app to your computer. If you already have the app, check to make sure that your version is updated and make yourself familiar with its use. Recommended light: Video Conference Lighting Kit For easy access and review, this list of The Polyvagal Practice Rules, Guidelines, and Technical considerations will be sent to you via email after signing up for the class. Payment After submitting the form you will be directed to a checkout form. Refund Due to the digital nature of this class that includes supporting materials and video recording of the class, all sales are final and non-refundable. Access You will have six months access to course material.I understand the group rules, guidelines, and E-Course disclaimer- Select -I AgreeI Do Not AgreeSubmit Previous