Fluence - Course Application Form

The intention of this brief application is to learn more about you, and pair you with the best possible course for your interests.

We will review your application within one week, and promptly send you a reply regarding acceptance. Upon acceptance, you will receive a link to the checkout page to complete your registration. (Certificate students will be manually enrolled with no need for further payment.) In the event we feel you are not a fit for the course we will let you know as soon as possible and make recommendations for other training, where applicable.

Name(Required)

Email(Required)

Are you currently enrolled in one of our Certificate Programs?(Required)

Yes

Which Program are you enrolled in?(Required)

Phone(Required)

Address(Required)

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

Website

What type of group are you applying for?(Required)

Which Reading & Study Group are applying for?(Required)

Which Clinical Consultation Group are you applying for?(Required)

Which other group training or course are you applying for?(Required)

Please specify which other group you are applying for:(Required)

Which section of the course are you applying for?(Required)

What is your clinical experience?(Required)

What is the highest degree you have obtained? If you have multiple, please list them(Required)

Please list any other certifications, continuing education courses, or relevant training experiences you have:(Required)

If you have attended previous Fluence workshops, including Premise & Promise or a ketamine course, please indicate them here:

Please tell us a little bit about your practice or profession, and what you hope to get out of this group.(Required)

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Course Application Form

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