General Application AEDP Immersion January 2021

AEDP Immersion Application

Please tell us about your license / credentials*

This course is intended 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" option

*Other from above: tell us about your "Other Licensed Mental Health Professional" license or credential

Why is this particular Immersion course of interest to you?*

Examples: 1) I am a Saturday sabbath observer and this course does not meet on Friday evenings or Saturdays where I live while most other Immersions do. 2) I have a special interest in learning from the African and /or Italian participants in this Immersion. etc. Please explain below - and thank you!

Your Full Name*

First Last

Professional Suffix (PhD, LCSW, etc)*

License Number (required for US Practitioners and everywhere where Licensing is required by law)

Address of the institution / private practice where you work.*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

COUNTRY*

Please tell us the country where you work for an institution or have a private practice so we can, if needed, a) learn about your country's licensing requirements AND b) call you in an emergency (we may need to find the country code!)

COUNTRY CODE for telephone and What'sApp outside of North America

Phone #*

Please Provide a Phone Number where we can reach you, ideally by text. We will not share this number or call you for marketing or other purposes.

Your Email*

Enter Email Confirm Email