Oct 2022 SCPTR Training Application Form

Salt City Psychedelic Therapy & Research Psychedelic Therapy Training Program (SCPTR PTTP)

Oct 17, 2022 Application - Deadline 10/09/22
Only complete applications will be reviewed

Please send any questions to info@scptr.org
Name:*

First NameLast Name
E-mail*
Phone Number*
Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Professional Title*
Company
Highest Level of Education
How did you hear about the program?*
Comments/Notes
Resume or Curriculum Vitae. .doc or .pdf *

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Background & Goals Statement. .doc or .pdf*

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Fewer than 1000 words. Follow instructions below Cancelof
This statement is completely Confidential.
Please include the following information in your Background/Goals statement:
1. Tell us how you hope to use this training.
2. What are your Goals?
3. Please share any therapeutic work in any aspect with adults (not children).
  You may include your work with: individuals, families, couples, or groups; hospital-based or outpatient; in private practice; performing intake assessments and mental status exams; offering pastoral care and spiritual direction; providing palliative and hospice care; substance abuse and dependency; trauma; and any ceremonial work.
4. Please include a description of any legal issues or License problems you have had, and the remedies to correct such problems
Professional References. .doc or .pdf*

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Please provide contact information for 2 references Cancelof
Are you Applying for a scholarship? *
Student or Veteran or Needs-based? Please briefly describe your scholarship need here. Please add a paragraph regarding your Need for scholarship in the background statement

Agreement- Training Application Fee$200.00

By Submitting this form, you agree to allow SCPTR to charge a payment of $200 that will be applied toward your full tuition. This will be refunded if you are not accepted to the program. Should you change your mind, it will not be refunded. Full tuition is due prior to the start of the program on 10/10/22. If you are applying for a scholarship, this will be reflected in your acceptance letter

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Salt City Psychedelic Therapy & Research Psychedelic Therapy Training Program (SCPTR PTTP)