Training Application
Questionaire

If you’re interested in the Ketamine Assisted Psychotherapy training and certification, please submit the application below and we will review your qualifications and if approved, send you the official registration for full payment

IMPORTANT!

Make sure you read our Provider Policies before submitting application

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

April 2025

Fall 2025

Winter 2025/2026

Line

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?

Line

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.

I understand and agree