EALC Application

• Your Full Name*First Last
• Your Email*Enter Email Confirm Email
• COUNTRY*Please tell us the country where you work and are licensed.
• Please tell us about your license / credentials*The role of EA is for mental health care professionals in the field of psychotherapy or similar professions. Tell us what type of license you have – choose from below, or complete the “other” optionChoose an authorized professionPsychologistPsychotherapistPsychiatristMarriage and Family TherapistSocial Worker*Other Licensed Mental Health Professional
• other, if needed, from above: Other Licensed Mental Health Professional” license or credential
• Please confirm that you have completed the prerequisites to be an Experiential Assistant*In addition to Immersion and Essential Skills (ES1), you need to have completed some AEDP Supervision such that an AEDP Certified Supervisor or Supervisor in Training will recommend you to join the EALC and are prepared to be an Immersion EA. Thank you!
  •  required: I have completed Immersion
  •  required: I have completed Essential Skills (ES1)
  •  required: I am currently in or have been in AEDP supervision (please provide your Supervisor’s name below)
• Name of your AEDP Certified Supervisor or Supervisor in Training*
• Languages spoken*All Institute sponsored courses require EAs to be fluent in English. Some courses include some participants who prefer to do experiential work in languages other than English. Please tell us about your proficiency in both English and in other languages.
  •  required: I am comfortable speaking English in course meetings
  •  I am comfortable assisting English speaking group formations
  •  I am fluent in other languages listed below
• Other languages I am fluent in
• Social Identitites: Ethnicity; socio-economic status; gender; sex; sexual orientation; national origin; first language; physical, emotional, developmental (dis)ability; age; religious or spiritual affiliation; race.**This information will be used ONLY to enhance diversity among EAs in our courses. ** Please tell us whatever you want us to know about your social identities and, if you wish, the identities of the clients you serve. 0 of 100 max characters
• Why do you want to be an Experiential Assistant?*
• Are you pursuing AEDP Certification?*
  •  Yes
  •  No
  •  Maybe / undecided
• Space to tell us anything else you want us to know: