Training Application: Cover Page

Application for IPSA Training – Part One: Cover Page


Date:
Name:
Street Address:
City                   Postal/Zip Code
E-mail:
Day Phone:
Evening
Best times to call:
Birthdate:
Gender:
Sexual Orientation
Academic History:
Work Experience (start with present work):
Mark the categories that represent your reasons for wanting to take the IPSA training:
——-    For personal growth
——-    To enhance my knowledge of sex therapy and develop new skills
——-    To eventually supervise surrogate partner therapy as a therapist
——-    To eventually work as a surrogate partner
——-    Other (please specify)
When are you available for training?
Any special needs or circumstances we should know about? Please explain
Mail completed application and $25 fee to: IPSA 3679 Motor Avenue, Suite 205, Los Angeles, CA 90034 (USA)
For further information or assistance please write to training@surrogatetherapy.org or call IPSA Senior Trainer Vena Blanchard at 310-836-1662.
For IPSA office use only:
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