Training Application: Questionnaire

Application for IPSA Training  Part 2 – Questionnaire


Please check any of the following that apply:
[_]Taken a grade school or high school course in sex education
[_]Taken a college level sex education class
[_]Taken classes/workshops focused on human sexual potential.*
[_]Read materials that increased knowledge and understanding of human reproduction and sexuality.*
[_]Trained to provide sex information (e.g., Sex Information Helpline, Planned Parenthood educator). *
[_]Received other types of training/education in area of human sexuality*

*List specific courses and dates on a separate page.


Please check all that apply:
[_]Received individual personal psychotherapy or counseling.
When and for what duration?
What kind of therapy was it?
[_]Participated in couple’s counseling. When and for what duration?
[_]Participated in family therapy. When and for what duration?
[_]Participated in a group therapy. When and for what duration?
[_]Attended workshops designed to enhance or improve your relationship skills (e.g., Marriage Encounter,
Landmark Forum, Human Awareness Institute) Please list all.
[_]Participated in Parent or Teacher Effectiveness Training (PET or TET)
[_]Received Peer Counselor training
[_]Taken a class or workshop designed to improve your communication skills:
[_]Participated in IPSA’s Personal Enrichment Program (PEP) or in a previous IPSA training.
[_]Participated in a 12-step groups (e.g. AA, Al Anon):

List any other sources of learning in this area (including reading)


[_]I have participated as a client in sex therapy (When and for how long?)
[_]My reading has encompassed the field of sex therapy (list authors and titles on a separate page)
[_]I have taken courses and/or read books and articles about psychology

List any other means of education in this area:


Please check if you have done the following work (as an employee or as a volunteer):
[_]Nurse, nurses aid
[_]A teacher, teacher’s aid
[_]Biomedical technician
[_]Massage therapist or physical therapist
[_]Mental Health worker
[_]Physical health educator
[_]Drug and alcohol counselor
[_]School counselor
[_]Full time parent
[_]Religious ministry

Please check if you have ever been employed by or volunteered for the following (name each center):

[_]A health or human services clinic:
[_]A hotline (list):
[_]Gay/Lesbian/Bi/Transgender center:
[_]A community service organization (list):

Please list all other volunteer work you have done:


Please check if you have ever taken
[_]A SAR Course (Sexual Attitude Reassessment)
[_]A sociology or cultural anthropology class
[_]A course that examined cultural and ethnic diversity
[_]A course that examined variations in relationship, lifestyle and sexual lifestyle choices

For each item on the following sexual orientations and lifestyles please indicate whether you are familiar with and understand this form of sexual expression
(0)not at all      (1)maybe slightly      (2)fairly well for a non-participant     (3) through reading and/or limited participation      (4)extremely well,      (5)intimately—through personal participation

__Intentional Celibacy
__Serial monogamy
__Illicit non-monogamy
__Open Marriage
__Homosexuality (gay male)
__B/D S/M
__Role playing
__Other (list)

(When writing your personal sexual evolution (see training application) please include describe your exploration of alternative lifestyles and how you arrived at your present idea of what is right for you and right for others.)

In your written application, feel free to list and describe all personal and educational experience that you believe will contribute to your skill, knowledge or comfort as a surrogate partner.