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.
| salon_application.docx |
