Braxia Institute Training Program Application Form

Braxia Institute Training Program Application Form

See https://braxiascientific.com/braxia-institute-2023/ for program details. All of the following information will remain confidential and only be shared within our selection committee. We appreciate you keeping your answers brief. If selected for an interview, you will be able to expand on all answers. At the end of this form you will also need to upload your CV. Please contact josh@crtce.com with any questions.
Full Name *

First Name Last Name
Email *
example@example.com
Phone Number
Please enter a valid phone number.
What city do you live in?
Age
Gender
Preferred Pronouns
Do you identify with a minority group? If yes, please describe or say 'prefer not to answer'
Please list any food allergies (for catering purposes)
Please describe your educational background, degrees and any professional designations (eg medical doctor, psychologists, social worker, etc). Please list in bullet points
Are you currently licensed to provide psychotherapy independently without supervision in Ontario? *

Yes No
Do you have a license to practice medicine in Ontario? *

Yes No
Please provide license number as applicable (eg CPSO, RP, RN, Clin Psyc number)
Do you have any legal history (eg history or arrests, pending charges, convictions, etc.)? *

Yes No
Have you ever lost your professional license or had practice restrictions (including previous or current restrictions)? *

Yes No
Are you currently working? If yes, please describe your current position(s)
Please select all therapy modalities and techniques that you are proficient in (eg can perform independently without supervision). Check all that apply

CBT DBT IPT ACT Psychodynamic psychotherapy Supportive therapy Psychedelic-assisted therapy Mindfulness Meditation Hypnosis Somatic therapy Emotion Focused Therapy Grounding techniques Prevention and Management of Aggressive Behaviours Trauma Therapy Group Therapy Family Therapy Other
How many years have you been independently practicing psychotherapy?
Part of the training program is a flipped classroom with peer teaching model with trainees teaching certain sections with supervision and support from our team. Please indicate which of the following sections you would feel comfortable teaching (with supervision and time to prepare). Check all that apply

Taking a personal and mental health history Appropriate use of touch Setting intentions Grounding techniques Calm Breathing techniques Ethical considerations in psychedelic medicine Key elements to set and setting Considerations for working as a dyad Self Care Spiritual Care History of psychedelics Understanding non-ordinary states of consciousness I do not feel comfortable teaching Other
Approximately how many patients/clients with depression have you treated?
Please describe why you are interested in training to become a psychedelic-assisted therapy provider
Describe your skills and experiences that would help you be an effective provider of psychedelic assisted therapy
Are there any potential barriers that may prevent you from fully participating in the training program? Please describe
Psilocybin Assisted Therapy will require one patient/client and two therapists to be together in an indoor room during the dosing session. Are you willing to comply with local public health guidelines and recommendations (e.g., hand hygiene, using required PPE and being fully vaccinated before the training program starts in July 2022)?

Yes No Prefer not to answer Other
If accepted into the program, are you available to attend the in-person training in the GTA this summer (July 23-24, 2022)? This session is in addition to virtual teaching sessions and ongoing group supervision.

Yes No Other
If accepted into the program, do you agree to complete all 4 component of the training (pandemic permitting)? [Component 1: Required reading (20-40 hours); Component 2: Team intensive training (2-day in person course) and ongoing virtual training sessions; Component 3: Practicum – hands-on experience in Mississauga clinic with 4 cases of psilocybin-assisted therapy (including 2 repeat dosing modules; total 6 dosing sessions) (20-30 hours per case, including 8-hour dosing sessions, preparatory sessions and integration sessions); Component 4: Ongoing group peer supervision.]

Yes No Other
Please confirm the following (please check all boxes to be considered for the program) *

I understand that self-administration of psychedelics is NOT part of this therapist training program. I agree to keep all training materials confidential and not share, reproduce or distribute to other individuals or groups. I will follow strict confidentiality and privacy rules to protect personal information of all participants in the program, including co-therapists and patient-participants.
Please list any questions or additional comments that you have about this program
Please upload an up-to-date CV that is signed and dated in PDF format

Cancel of
E-Signature (by signing, you attest to all of the above statements being true to the best of your knowledge)

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