Join At the Core

Please fill out this application, I look forward to being in touch soon! If you encounter any questions please reach out.

Name

First Name

Last Name

Pronouns

Phone

(###)

###

####

City/State/Country of practice

Time Zone

Preferred Payment Plan

Professional Background

Degree and Licensure

Date you recieved your license

YYYY

Current Workplace(s) and Role(s)

Have you had any training in trauma treatment or other related modalities? (If yes, please briefly describe)

Have you had any previous training in AEDP? (if yes, please describe)

Have you taken a training or course with me before? (If yes, which one?)

What are you hoping to gain from this group?

Anything else you want me to know?

How did you hear about this training?