Please complete this form before your first training weekend. It records your license information, your supervision status, and your agreement to the WellMind Training Academy attendance, consultation, confidentiality, and refund policies.

If you need to correct something after submitting, email wellmindtraining@wellmind.me rather than submitting the form a second time.

Name

License Number (enter N/A if not applicable)

Are you currently practicing under supervision?

Yes, I practice under supervision

No, I am independently licensed

Supervisor name (if supervised)

Supervisor email (if supervised)

I have read and agree to the WellMind Training Academy participant agreement, including the attendance, consultation, confidentiality, and refund policies.

Type your full legal name as your signature

Phone Number

State

License Type

I understand this training is experiential: in practicum I will process my own real memories, not hypothetical material. This may bring up distress or unexpected emotion. I understand the training is educational and is not personal therapy.

Submitting this form also adds you to WellMind Training Academy cohort emails. Training logistics, consultation dates, and schedule changes are sent this way.