Name
*
First Name
Last Name
Email
*
Phone
*
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Training Date
*
Please select the date options you are interested in
Optional Ketamine Experience
*
Professional Licensure Info
*
Please list your license and credentialing information
Please describe your background and interest in this training. Have you worked with Ketamine or psychedelics previously? Please describe any previous experience with non-ordinary states of consciousness that you believe are relevant to this training.
*
Tell us anything pertinent regarding your personal development and progress through the stages of licensure or employment that might relate to your interest in this program.
*
What areas have you received therapeutic training in and/or what client populations do you work with?
*
What therapeutic (psychological, spiritual, physical) self-care routines do you currently have in place that help support you?
*
Are there life events, adversity, trauma that have triggered your interest in this work, and have any experiences with non-ordinary states furthered your growth?
*
Please share with us briefly what you hope to do with this training in your work in the world.
*
Is there anything else you feel we should know about you in your consideration of acceptance for this training?
*
I acknowledge that I read and agree to the Provider Polices above. While this training imparts a wealth of knowledge and observation of the KAP process, because of its experiential nature, most people also find it deeply enriching of their own process and personal process and life events. We support and integrate the deep personal issues that may come up. However, we do state that this is not primarily a workshop for personal counseling, and you may not be able to use it to do the work that should be done in personal therapy. You may have much more to bring though in your own personal work afterwards.
*
Thank you! What' are the next steps?
1. Your application will be reviewed
2. You will get set up in our portal system where you will be able to upload payment info and pay the $500 deposit
Once application is approved & $500 deposit is paid, your spot in the training is secured
3. A brief interview with both Tony & Jess or one of them will be scheduled via video
