Fluence - Ketamine-Assisted Psychotherapy Certificate Program Add-On Application

This is the application form for Fluence’s Ketamine-Assisted Psychotherapy Certificate Program. This application is for applicants who have already applied or enrolled in the pre-requisite Certificate Program in Essentials of Psychedelic Therapy. If you have not already enrolled in the Essentials program and wish to apply to the program, please use this applicatio n instead. You are encouraged to review the Certificate Program page and our FAQ before applying. If you still have questions don’t hesitate to contact us!

Identifying Information

Name(Required)

Email(Required)

In which PTI cohort have you already enrolled?

Have there been any changes to the status of your education , training, or license since applying to the PTI program? (Eg. graduated from program, obtained licensure, had license revoked, etc)

Yes

Please explain the changes to the status of your education, training, or license since applying to the PTI program.(Required)

Do you have any experience providing KAP?(Required)

Yes

Please briefly describe your existing KAP experience.(Required)

What are you hoping to gain from your experience in this program?(Required)

Cohort Selection and Cost

Which cohort are you interested in joining for the live portion of the program?(Required)

Do you understand that the cost for this program is $3,000 USD?(Required)

Yes, and I intend to pay in full before the start of the program.

Yes, but I intend to make use of the installment plan and make 3 equal payments of $1050 for a total of $3150.

Ketamine-Assisted Psychotherapy Certificate Program Add-On Application

Identifying Information

Cohort Selection and Cost

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