Psychotherapy Practice Development Salon Application for Program Participation Please complete and submit for consideration for program participation. Date: _____________________ Name_____________________________________________Telephone___________________ Address_______________________________________________________________________ Email_________________________________________________________________________ How did you hear about the Salon?
Date you became: Licensed __________ or Registered Intern __________ or check here if Neither ___ ** If currently being supervised, please give the name and phone number of your supervisor: ____________________________________________________________ ______________________ If not in private practice now, when do you expect to begin?______________ In practice now: ___Part time (10 hrs or less) ___Full time Do you have any physical or emotional restrictions that would limit your participation in this program? If so, please explain ________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ * PLEASE INCLUDE YOUR CURRENT RESUME WITH YOUR APPLICATION. ** Submit application materials via mail to:
John Nickens, PhD, c/o SALON APPLICATIONS, 465 - 34th Street, Oakland, California, 94609 Click the icon below to download a copy of the Salon application.