Practitioner Training Registration

1. Training Registration

Which training are you registering for? *

OnlineIn-PersonNot sure yet

2. Contact

Full Name *

Email *

Phone *

Mailing address *

City, State/Country, and time zone *

3. Education & Professional Background

Which field best describes your practice? *

Medical ProviderPsychotherapistCoach

Education *

Years in practice *

Practice or workplace name *

Professional title *

Professional licenses or credentials * (include state and license type)

Professional certifications * (enter “None” if not applicable)

Trainings completed *

Areas of specialization *

Current modality or training background (e.g., EMDR, IFS, EFT, Brainspotting)

4. KAP & Psychedelic Experience

Personal experience with KAP or psychedelic medicine * (include approximate number of experiences)

Professional KAP experience * (include years in practice and approximate number of clients or sessions)

What is your prior experience with experiential, somatic, or psychedelic training?

5. Current Practice & Client Population

Which types of clients do you currently serve? *

Are you currently providing or planning to provide psychedelic-assisted services? *

Currently providingPlanning to provideExploring / not sure yet

What brings you to this training right now? *

6. Intentions & Training Fit

What do you most hope to gain from the training? *

Which experiential path are you most drawn to? *

Any concerns you would like Dr. Gold to address?

Personal hobbies or interests

Dyad partner request (a specific person or preferred professional background)

7. Prior Training & Cohort Preferences

Have you completed any of Dr. Phil Wolfson’s trainings?

YesNo

If yes, which one(s)? (used to verify professional discount eligibility)

Professional courtesy discount qualification

Select the strongest qualification you would like Sarah and Dr. Gold to verify. The discount is issued only after the corresponding certificate is reviewed.

Certificate(s) of completion

Upload up to five PDF, JPG, PNG, or WebP files (10 MB each). Files are stored privately and are available only to Lisa and Sarah for verification.

I am applying for the Founding Cohort (first 25 enrollees).If I’m not a fit for this cohort, notify me when the next cohort opens.

Add me to Dr. Gold’s practitioner training contact and mailing list.

Any information used for research will be de-identified before analysis or reporting.

I consent to my information being used anonymously for research to improve the course and app and expand the field of psychedelic science.I agree to complete assessments before the course, one week after the course, one week after a psychedelic experience, and at a one-year follow-up.

Signature (type your full name) *

Date *