Fluence - Advanced Psychedelic Harm Reduction and Integration Certificate Program Application

This is the application form for Fluence’s Advanced PHRI Certificate Program. This application is for new applicants who have not yet applied or enrolled in the prerequisite Certificate Program in Psychedelic Therapy and Integration. If you have already enrolled in the PTI program and wish to apply to this program, please use this abbreviated application instead. Upon completion of the form you’ll be taken to a page to process the $100 application fee. 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)

Phone(Required)

Address(Required)

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

Date of Birth(Required)

Preferred Pronouns

Please provide a link to your professional practice website, profile, or other public-facing resource (Psychology Today listing, LinkedIn page, etc.)

Please upload a copy of a form of government issued ID (eg. drivers license or equivalent)(Required)

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 50 MB.

Where did you hear about Fluence (select all that apply)(Required)

Please specify(Required)

Education, License, and Experience

What is the highest level of education you have completed?(Required)

What is the field of study for the highest level of education you have completed?(Required)

If you have completed or are you currently enrolled in any courses or programs with Fluence, please indicate them here.

Please describe any additional degrees, graduate work, certifications, continuing education courses, or relevant training experience you have completed.

Do you hold an active license or registration to practice psychotherapy in good standing in your jurisdiction?(Required)

Please indicate your progress towards licensure by explaining your current course of study and institution.(Required)

Please upload evidence of your current course of study (transcript, letter of enrollment, etc)(Required)

Accepted file types: jpg, pdf, doc, png, Max. file size: 50 MB.

Please indicate your license: [Select all licenses you hold](Required)

In which states or territories are you licensed/registered?(Required)

What is the name of the licensing board(s) with which you are licensed or registered?(Required)

What is your license/registration number?(Required)

Do you attest that you have (a) not had any professional license(s) suspended and/or revoked; and/or (b) not been subject to any other form(s) of professional sanction and/or discipline in connection with actual or alleged negligence and/or misconduct?(Required)

As a licensed or pre-licensed clinician, how many TOTAL hours of psychotherapy, counseling or behavioral health services have you provided, in any setting? (TOTAL hours should include pre-licensed psychotherapy and counseling hours gained working toward licensure)(Required)

Which best describes the setting of your clinical practice? (Select all that apply).(Required)

Individual private practice

Group practice (eg. private clinic)

Larger institution (eg. hospital)

Please provide the name of the group practice or institution where you practice(Required)

Please describe the focus of your practice including your clinical orientation, the population you treat, and the setting(s) in which you work.(Required)

If your professional practice incorporates the use of non-ordinary states of conscious, or contemplative and mindfulness-based approaches, please tell us a bit about it here.

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

Demographic Questions

Fluence is committed to providing an inclusive education program for a diverse group of clinicians and accessible and culturally relevant treatment to diverse patient populations. While the following questions explore individual categories of identity separately, we recognize these categories and lists are not exhaustive. We value every applicant’s complexity, acknowledging you each hold many identities, and each of your multiple identities interact and intersect in unique ways. Your responses will help us evaluate our program, policies, and recruitment strategies. If you have any questions or concerns, please let us know!

With which racial or ethnic group(s) do you identify? (select all that apply)

Multiracial / Multiethnic Asian

Black or African descent Latinx

Middle Eastern or North African

Native American / First Nations / Indigenous Pacific Islander

White / Caucasian / European

Prefer not to say

Some other race, ethnicity, or origin

Please describe your race, ethnicity, or origin in your own words.

We realize that the racial/ethnic categories listed above encompass many different nationalities. If you are interested in sharing more, please describe your nationality (e.g., Armenian, Puerto Rican, Vietnamese).

With which gender do you identify?

Female

Male

Nonbinary / Gender nonconforming / Gender fluid Two-spirit

Prefer not to say

Other

Do you identify as transgender?

Do you identify with any of the following identities: Asexual, Bisexual, Fluid, Gay, Lesbian, Pansexual, Queer?

Do you have a disability or impairment?

If you have a disability or impairment and feel comfortable sharing it, please describe it here.

Do you identify as neurodivergent?

Are currently serving in the U.S. Armed Forces, National Guard, or Reserves?

Are you a veteran?

Cohort Selection and Cost

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

Which cohort are you interested in joining for the live 10 week core class?(Required)

You have indicated you are not available for the April/May or June/July PTI cohorts, in which case you will not be able to join the Spring cohort of PHRI. Please go back and select the April/May or June/July PTI cohort, or you can proceed with your application and we will notify you when future PHRI cohorts are posted.

Do you understand that the cost for this program is $5,500 USD?(Required)

Yes, and I intend to pay in full

Yes, but I intend to make use of the installment plan and make 3 equal payments of $1925 for a total of $5775.

Did someone refer you to this program and provide you with a referral code?(Required)

Yes

Please input your referral code here.(Required)

Do you understand that after submitting this application, you will be redirected to a page to process a non-refundable $100 application fee, and that your application will not be processed until receiving this payment?(Required)

Yes, I understand.

Advanced Psychedelic Harm Reduction and Integration Certificate Program Application

Identifying Information

Education, License, and Experience

Demographic Questions

Cohort Selection and Cost

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