Application for our Entheogenic Medicine Training Program in Ketamine-Assisted Psychotherapy
This form is the first formal step toward enrolling in our training program. Please read every question in its entirety before answering. After reviewing your application we will either contact you for more details or send you link to pay for the course and provide further instructions.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
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City
State / Province
Postal / Zip Code
Some Basics
How did you hear about us? Please be specific.
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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?
Experience
What Is your professional background?
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Not a licensed professional
Psychotherapist (PsyD/Phd/MA/MSW)
Medical Doctor (MD/DO)
Naturopathic Doctor (ND)
Acupuncture/Asian Medicine (LAc)
Nurse Practitioner (NP)
Other licensed professional
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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Please describe why you would like to take this training
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Please upload your most recent CV or resume.
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To be awarded a complete certificate we require the experiential module. However, you may take one or the other depending on your level of prior experience.
Didactic only (pre-recording lectures and online workshop)
Didactic + experiential (eligible for certificate)
Experiential only
I want to do my experiential at:
Synaptic Institute in Portland, OR
AIMS Institute in Seattle, WA
Which option would you prefer for your experiential component at Synaptic?
One-on-one ($1450)
Next available group experience ($400)
I want to pay for the course by:
ACH for no additional charge
Debit/Credit card with a 3% fee
Submit
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