Application for IPSA Training
City Postal/Zip Code
Best times to call:
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 email@example.com 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