First Name*

Last Name*

Pronouns

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Application Narrative

Please answer the first question. Next, select TWO (2) additional questions to answer.

What draws you to consider the Green House program?*

Additional questions:

Please select two additional questions to answer below.

1) Name one or two specific learnings you have gained, in terms of your clinical understanding and experience, from your own depth/psychodynamic/long-term personal therapy experience?

2) What interests you about working with marginalized clients? What has your experience (clinical or otherwise) been with this population?

3) What goals might you have for your learning experience in the Green House program?

4) What do you imagine the future impact of this program might be for you?

Resume File Attachment*

Accepted file types: pdf, doc, docx, odf, Max. file size: 300 MB.

PDF, DOC, DOCX, ODF

Digital Signature (type full name)*

Today's Date

Professional Accreditations