6536 SE Duke St. Suite 7 Portland, OR 97206 | info@synaptic.care 971-403-0884 | www.synaptic.institute
Cohort: 001
Application Deadline: October 31, 2022 Course Begins: November 1, 2022
Application for the Entheogenic Medicine Training Program
This form is the first formal step toward enrolling in our training program. Please read every question in its entirety before answering. All answers will be kept confidential. We understand that it may make some people uncomfortable to put their experiences in writing. Please offer as much as you can. After reviewing your application, we will send you an e-mail to either invite you to an interview or let you know we do not feel our program is the right fit for you. After an interview, we will either offer you a position which can be secured with a $150 registration fee, add you to a waitlist for the next cohort, or let you know that we feel our program is not the right fit for you. You application is not complete until you pay the $20 application fee.
Name
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First Name
Last Name
Email
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Phone Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Statement of Nondiscrimination
Synaptic Training Institute prohibits discrimination against its customers, employees, and applicants for employment and student applicants on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Synaptic Training Institute
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Some Basics
How did you hear about us? Please be specific.
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Have you been an Oregon resident for more than two years?
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Yes
No
Are you at least 21 years of age?
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Yes
No
Do you have a high school diploma or GED?
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Yes
No
Which of the following best applies to you concerning the potential results of a criminal background check?
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I have nothing to report
I have some some history
Other
Please explain
Do you identify with any underrepresented or marginalized identities?
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Yes
No
Maybe
How do you identify?
More demographics
For accreditation purposes we are required to collect the following data as described.
Date of Birth
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Month
-
Day
Year
Date
Gender
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Veteran status
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Disability status
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National origin
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Race or Ethnicity
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Hispanic or Latino
Native American or Alaskan Native
Asian
Native Hawaiian or Pacific Islander
African American
Caucasian
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Experience
What Is your professional background?
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Psychotherapist (PsyD/Phd/MA/MSW)
Medical Doctor (MD/DO)
Naturopathic Doctor (ND)
Acupuncture/Asian Medicine (LAc)
Nurse Practitioner (NP)
Other licensed professional
Not a licensed professional
If applicable, in what state are you licensed and what is your license number?
What, if any, is your professional specialty?
Please describe what training you have received in psychedelic medicine. Include what institution or teacher it came from, approximate number of hours, when you did it, and what it did or did not include, etc.
What experience, if any, do you have in working with people in altered states?
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Uploads
Please upload a one-page cover letter.
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Please upload your most recent CV or resume.
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Please upload a letter of recommendation or have it e-mailed to info@synaptic.care.
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Please upload a photo of your driver's license or passport for identity verification.
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Financial Aid
We understand the significant cost of this and comparable programs and want to do everything we can to make it as accessible as possible to people of diverse socio-economic backgrounds. That is why we will be offering several tiers of scholarships in each cohort. Upon reviewing your entire application, we may offer a position in the cohort with or without a scholarship based on resources and the applicant's need. You will be required to apply for a scholarship through the Sheri Eckert Foundation, which, if granted you can use at any of the state accredited training programs.
Will you be applying for financial aid?
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Yes
No
Have you applied for a scholarship from the Sheri Eckart Foundation?
Yes, and I received a scholarship
Yes, but I was not granted a scholarship
No, but I am going to
Other
What is your annual household income?
Please describe why you are applying for financial aid, whom you plan to serve, and how your participation or perspectives will be an asset to your cohort and the community.
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Final Step
A non-refundable $20.00 application fee is required for your application to be processed.
Payment
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