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 3428 Motor Avenue, Los Angeles, CA 90034 (USA)

For further information or assistance please write to training@surrogatetherapy.org or call 310-836-1662.

For IPSA office use only:

A     Q      SxEvol     Essays: 1    2    Refs: 1   2     fee          Intrvw’d          Accptd Y     N   Class date               fees                dep     bal               rec’d.     tr cert.      Intrnshp compltd          Full Cert