Fluence - Certificate Program Application

Name(Required)

What pronouns do you use?

Email(Required)

Phone(Required)

What is your mailing address?(Required)

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

Where did you hear about Fluence?(Required)

Which program are you applying for?(Required)

Indicate your profession (Psychologist, Social Worker, Nurse Practitioner, etc.).(Required)

Where is your clinical practice located?(Required)

Select if same as mailing address above

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

I have a practice in more than one location

Clinical practice second location

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

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

What is the highest degree you hold?(Required)

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

If you are affiliated with any psychedelic-oriented groups, societies or organizations, please list them here.

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

If there is anything else you would like to share about yourself or your practice, please enter it here.

Please upload a copy of government issued ID(Required)

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

The HECC requires that you provide an emergency contact with your application. Please provide that information here:

Emergency Contact Email

Emergency Contact Phone

Postgraduate Certificate programs require readings between 20-40 pages per week for the duration of two 12-week courses. Attendance is mandatory for our live/online courses, and meetings are not recorded. Are you willing to commit to our reading and attendance requirements?(Required)

Yes

This program includes both weekly self-paced and live-online sessions, as well as a 30-hour in-person intensive. Are you willing and able to set aside at least 3 hours per week to study and participate in the program, as well as devote 35 hours over the course of 5 days to the in-person program?(Required)

Yes

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)

Yes

Do you understand that the cost for the program is $9550 USD?(Required)

Do you understand that the cost for this program is $7450 USD?(Required)

Do you understand that the cost for this program is $5570 USD?(Required)

Certificate Program Application

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