Student Inquiry of Interest Form | Qigong Sensory Training Institute

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Email *

Phone Number

Mobile Phone

Preferred Service for Video Conferencing

Primary Language

Course *

Your Relationship to the Child

e.g. mom, grandmother

Does your child have a medical and/or educational diagnosis of autism?

Does your child have any other medical problems or diagnoses?

If yes, please specify:

Is your child taking medications and/or supplements?

If yes, please specify:

Is your child receiving any other treatment for autism at this time and/or are you planning to start any new treatments soon?

If yes, please specify:

Please check each of the following statements to signal your agreement and understanding of the responsibilities you will have as a parent/caregiver of the child receiving treatment:

I agree to attend treatment sessions as scheduled with my QST Certified Trainer.
I agree to complete the pre- and post-test surveys for my child in a timely manner.
I will complete the online parent training course and assignments on schedule.
I will review the required consent form and will sign prior to the course.

By submitting this form, I certify to the truth and accuracy of the information provided on this inquiry form. By submitting this form you will be added to our mailing list.

Course Start Date

Please check each of the following prerequisites to show that you have met them.

I am healthy, energetic, and taking little or no chronic medication. The reason for this requirement is that Qigong Sensory Treatment (QST) utilizes the energy, intention and sensibility of the QST Certified Trainer. According to Chinese medicine, chronic illness and chronic medication decrease a person’s overall energy and sensitivity, and thus the resources they bring to bear in working with QST.
I have two or more years of professional or para-professional experience working with children on the autism spectrum OR
I am a parent or close family member of a child with autism.

Please describe the work you have done with young children on the autism spectrum:

Please check each of the following statements to signal your agreement and understanding of your responsibilities to be a participant in this training course:

Recruit a family before the beginning of the course with a child that meets the eligibility criteria to participate in the training. Eligibility criteria can be found here: https://bit.ly/3lQ8KKk
Ensure that the child's parent/guardian completes a registration form, medical history, consent to work with form, consent to video form, and agreement to work with the QST CT candidate for the duration of the course no later than four weeks prior to the beginning of the training.
Schedule treatment sessions with supervising Master Trainer.
Attend conference calls on dates and present my case study.
Assist in the collection of pre- and post-test data for the child with whom I am working.
Complete all treatment sessions with the child /family with which I am working.
Hold an exit interview with parents.
Complete and submit therapist agreement form.
At the end of the course, destroy any recorded material of treatment sessions made during the course.
Most therapists find that distance supervision works well for them. Occasionally a therapist has found that their learning style is not a good match for distance supervision. In-person supervision is normally unavailable, unless a therapist and supervisor happen to live near each other. Therapists who are not able to master the treatment with distance supervision will not be able to successfully complete the course and graduate.

By submitting this form, I certify to the truth and accuracy of the information provided on this inquiry form. By submitting this form you will be added to our mailing list.

Please initial each of the following statements to signal your agreement and understanding of your responsibilities to be a participant in this training course:

I am a QST Certified Trainer in good standing with QSTI.
Attend conference calls and course work as required.
Complete and submit QST Certified Trainer Down Syndrome Endorsement agreement form.

By submitting this form, I certify to the truth and accuracy of the information provided on this inquiry form. By submitting this form you will be added to our mailing list.

Please initial each of the following statements to signal your agreement and understanding of your responsibilities to be a participant in this training course:

I am a QST Certified Trainer in good standing with QSTI.
I have successfully worked with 4 children in an in-person setting.
Attend treatment sessions with supervising Master Trainer.
Attend conference calls as scheduled and complete course requirements.
Complete and submit QST Certified Trainer Online Parent Trainer Endorsement agreement.

By submitting this form, I certify to the truth and accuracy of the information provided on this inquiry form. By submitting this form you will be added to our mailing list.

Please check each of the following statements to signal your agreement and understanding of your responsibilities to be a participant in this training course. I declare that:

I am a QST Certified Trainer in good standing with QSTI.
I am healthy, energetic, and taking little or no chronic medication. The reason for this requirement is that Qigong Sensory Training (QST) utilizes the energy, intention and sensibility of the QST therapist. According to Chinese medicine, chronic illness and chronic medication decrease a person’s overall energy and sensitivity, and thus the resources they bring to bear in working with QST.
I have completed a course of treatment with at least 12 families with children ages 2-12 and demonstrated positive outcomes on pre-/post-test results.

I agree to:

Submit pre-post SSRC data on 12 children I have worked with as a prerequisite for participating in the Master Trainer course and an Excel spreadsheet with a summary of the pre-/post-test scores.
Co-teach a QST CT course with a Master Trainer.
Supervise a minimum of two therapists in training during the clinical supervision portion of the QST CT course, with supervision support from a Master Trainer.

I understand that I will be required to:

Demonstrate full knowledge of the QST treatment protocol methodology.
Demonstrate the ability to interpret and adapt the QST treatment to children’s responses.
Demonstrate the ability to effectively connect, communicate, and coach a variety of parents/families and therapists in training.
Demonstrate flexibility in approach to difficulties presented by therapists in training, parents and children.
Receive recommendation of Master Trainer re: authorization as a Master Trainer.

I understand that:

Most therapists find that distance supervision works well for them. Occasionally a therapist has found that their learning style is not a good match for distance supervision. In-person supervision is normally unavailable, unless a therapist and supervisor happen to live near each other. Therapists who are not able to master the treatment with distance supervision will not be able to successfully complete the Master Trainer course and graduate.

By submitting this form, I certify to the truth and accuracy of the information provided on this inquiry form. By submitting this form you will be added to our mailing list.