Fluence - Psychedelic Therapy and Integration Certificate Application

Identifying Information

Email(Required)

Phone(Required)

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?(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)

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.

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)

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!

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).

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 are you interested in joining for the 6-week live portion of the program?(Required)

Please input your referral code here.(Required)

Psychedelic Therapy and Integration Certificate Application

Identifying Information

Education, License, and Experience

Demographic Questions

Cohort Selection and Cost

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