Practitioner Membership Application

Collecting basic info from practitioners who are interested in becoming members of Refuge

Name(Required)

First Last

Email(Required)

Phone(Required)

How did you hear about Refuge?(Required)

If applicable, please name the person who referred you to Refuge

Which of the following best describes your current professional context?(Required)

Private practice

Practice at a private clinic

Practice in public sector

Supervised practice

Internship

Other

You may select more than one option

Please select the therapeutic approach(es) that best capture your area(s) of expertise(Required)

Minfulness/ACT

Cognitive Behavioural

Internal Family Systems

Emotion Focused Therapy

Transpersonal

Humanistic

Psychodynamic

You may select more than one option

What is your professional title?(Required)

At what stage of your career are you?(Required)

Please indicate your level of experience with psychedelic-assisted therapy.(Required)

No experience

Providing Psychedelic Harm Reduction and Integration Therapy

Have provided ketamine-assisted therapy to 3 or fewer clients

Have provided ketamine-assisted therapy to more than 3 clients

Have provided psilocybin- and/or MDMA-assisted therapy

Have provided group psychedelic-assisted therapy

You may select more than one option

Please indicate your level of training in psychedelic-assisted therapy.(Required)

No training

Training in Psychedelic Harm Reduction and Integration

MAPS training

At least one training on assisted therapies from a recognized provider

Several trainings on assisted therapies from a recognized provider

Completed certification from a recognized provider

You may select more than one option

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