Enrollment Form

First Name *

Last Name *

Degree(s) * If not applicable, type "None".

Occupation(s) * If not applicable, type "None".

Email *

Phone *

Street Address *

City *

State *

Zip Code *

Country *

If licensed by your state to diagnose and treat, list your current license(s) and the state(s) that grant them:

List any current hospital, academic, institutional, governmental organizations with which you are affiliated:

Please indicate the highest level of AGI training you've completed: * No Prior AGI Training FIGI Completed Level 1 Completed Level 2 Completed Level 3 Completed Certification Completed Faculty Training Completed

If you've had prior trainning, when, where, and from whom did you receive other training in guided imagery?

What clinical approaches do you utilize most commonly?

What special problems do you treat most commonly in clinical practice?

How do you intend to use your advanced training in IGI℠? *

Enrollment Contract: * I agree to the Academy of Guided Imagery's Agreement.

Upload your signed Student Contract. * Select Print, sign, scan, and upload your Student Contract here. (File Types Accepted: .doc, .pdf, .jpg, .jpeg, .png, .zip)

Clinicians: As a state licensed clinician, I have submitted a copy of my license(s).

Select Upload a copy of your license(s). (File Types Accepted: .doc, .pdf, .jpg, .jpeg, .png, .zip)

Students: As a student pursuing a credential that will lead to a professional license, I have sent a copy of my Student ID.

Select Upload a copy of your Student ID. (File Types Accepted: .doc, .pdf, .jpg, .jpeg, .png, .zip)

Educator / Coach / Clergy: As a coach, health educator, or member of the clergy, I have submitted a brief (one to two page) application letter describing my goals in learning IGI℠; my plans for using it; my access to psychological consultation or supervision, if needed; any previous training or experience I've had in counseling or coaching; and a copy of my CV or resume.

Select Combined the required documents listed above into a single PDF and upload it here. (File Types Accepted: .doc, .pdf, .jpg, .jpeg, .png, .zip)

Promissary Note: If I've chosen an Extended Payment Plan, I have signed and submitted my Promissary Note.

Select Print, sign, scan, and upload your Promissary Note here. (File Types Accepted: .doc, .pdf, .jpg, .jpeg, .png, .zip)

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