Application for the Couples Therapy Training Program

Please complete the form below to apply to the Couples Therapy Training Program. Any questions can be directed to Michael Wannon at menaw1@aol.com.

An application fee of $50 needs to accompany this application. If you choose to pay that fee via credit card now, continue the application on this page. If you prefer to pay by check, please click here.

Application Form - Couples Therapy Training

Name
First Last
Date of Birth
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone Number
Email
Business Address
Street Address Address Line 2 City State ZIP Code
Business Phone
Preferred Mailing Address
- Home Address
- Business Address
Attach a Copy of your most recent CV
Drop files here or
Max. file size: 256 MB.
Current Malpractice Insurance Coverage
Please list your current insurance carrier.
Attach a Copy of your Current Malpractice Insurance Coverage
Drop files here or
Max. file size: 256 MB.
Education
List the College/University you attended, your Major, # of Credits, Degree and Date of Graduation.
Mental Health Training (Internships, Residencies, Institutes, etc.)
List the name of the Institution, Course/Programs, Dates and Supervisors.
Clinical Experience
List your training & professional experiences, listing most current first. Include Dates, Client Age Range, Treatment Modality, Setting (Hospital/Clinic), Hours per Week, and Supervision (Type, Individual, Peer, Group, etc., and Frequency).
Other Professional Activities
e.g. research, teaching, community work, writing, etc.
Personal Psychotherapeutic and/or Psychoanalytic Experience
List the type of psychotherapy (individual, family, couples, group), the therapist's name(s) and theoretical orientation(s), when, how often, and how long.
Attach files here if you do not have adequate room in the designated spaces above or upload your CV here as well.
Drop files here or
Max. file size: 256 MB.
Hidden
Old - Attach files here if you do not have adequate room in the designated spaces above or upload your CV here as well.
Max. file size: 256 MB.
Couples Application Fee
Couples Application Fee*
A $50 application fee is required with the submission of the training application. this fee is non refundable, but will be applied to your tuition.
Price:
Total
$0.00
Credit Card*
Card Details
Cardholder Name
Email
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Application Form - Couples Therapy Training

Couples Application Fee