Braxia Institute Training Program Application Form

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

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

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

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

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