Certificate Program in Spiritually-Informed Psychotherapies – Application & Instructions

APPLICATION REQUIREMENTS

Application deadline is Wednesday, June 5, 2019 and must include:

• Completed application form (see below) with your $40.00 nonrefundable application fee (included with ticket purchase)

Once you have finished and submitted your application form online, you will be redirected to the EventBrite page where you can purchase your ticket. 

Jessica E. Heller, MPS, ATR-BC, LCAT
Psychotherapy & Spirituality Institute
120 Broadway 38^th Floor
New York, NY 10271

Full refunds available to those who withdraw by 5/1/19. A 50% refund available to those who withdraw by 6/12/19.  No refunds will be granted after the first day of the program.

APPLICATION

2019 Certificate Program in Spiritually-Informed Psychotherapies

Date *

Your Full Name *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Fax Number

Email Address *

Current school/continuing educational program (if applicable)

Prospective date of completion

Number of Hours of Instruction

Professional Title (check all that apply)

Health Care Professional

Clergy/Minister

Physician

Mental Health Counselor

Psychologist

Social Worker

Creative Arts Therapist

Other Certified Specialist (please specify)Other Certified Specialist (please specify)

Position

Place of Employment

City

State

Current License Held

License Number

State

List All Other Current Certifications

Earned College Degree(s)

School(s) attended for Degree(s)/Location(s)/Date(s) of Completion

How did you hear about our program?

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Statement of Purpose (Why are you interested in the program?) *

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