IPI Psychedelic-Assisted Therapy Training Application

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Email* This field is required.
example@example.com
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First Name* This field is required.
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Last Name* This field is required.
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Pronouns
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Date of Birth* This field is required.
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Address * This field is required.
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Cell Phone Number* This field is required.
Area Code
Phone Number
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Work Phone Number * This field is required.
Area Code
Phone Number
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Education: (Please list your highest degree and area of study):* This field is required.
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Please list all professional licenses with license number, state(s) issued, and status. You must include active, inactive, restricted or suspended licenses. (In order to qualify for the program you must have one of the following credentials: Professional Clinical Counselor (LPC), Marriage and Family Therapist (LMFT), Clinical Psychologist (PhD/PsyD), Licensed Addictions Counselor (LAC), Clinical Social Workers (LCSW), Pre-licensed therapists (MA), Chaplains (M.Div.), Physicians (MD/DO), Nurse Practitioners (NP))* This field is required.
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If you are not a licensed or a graduate of a masters-level or equivalent psychotherapy program, please explain below how you have 1000 direct contact hours of mental health interventions.
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If you are a medical provider, please list the type of board certification you have?
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How did you hear about us?* This field is required.
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Introduce yourself and describe your psychotherapy training and your current practice setting.* This field is required.
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Describe some of your self-care practices* This field is required.
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Describe, if any, your experience with psychedelic-assisted therapy* This field is required.
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How do you see yourself using the knowledge from the training?* This field is required.
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Why do you want to be a part of a community of practitioners learning psychedelic therapy?* This field is required.
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How do your skills and gifts contribute to the program?* This field is required.
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What most excites you about this program? After completing this question please hit submit and you will be redirected to a calendar to schedule your discovery call. Your application is not complete until you schedule your discovery call. * This field is required.
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