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PATH Membership Application
Thank you for your interest in joining PATH! We're excited to learn more about you. Please share the following information so that we can confirm your membership.
What should we call you?
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How should we be in touch?
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Where do you live?
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Where do you work?
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Under what professional degree are you licensed?
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Under what professional degree are you licensed?
A
Social Work (LCSW / LICSW)
B
Counselor (LCPC)
C
Psychologist (PhD / PsyD)
D
Drug Addiction Counselor (LDAC)
E
Acupuncture (MAc)
F
Massage Therapist
G
Nurse Practitioner (PhD, CNP)
H
Physician (MD / DO)
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Other
Please list any of the following that you have:
District of Columbia License Number
Maryland License Number
Virginia License Number
What would you like us to know about you?
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What do you hope to gain from your membership in PATH?
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Please list any of the following that you have:
Where did you learn about ketamine and psychedelic assisted psychotherapy?
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Where did you learn about ketamine and psychedelic assisted psychotherapy?
California Institute for Integral Studies
DMV Ketamine Training Center
Fluence
Integrative Psychiatry Institute
Ketamine Training Center
Naropa University
On-the-job training with employer
Polaris Insight Center
PRATI
Self-study
Synthesis Institute
Other
Do you want to be included in our Provider Directory?
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Do you want to be included in our Provider Directory?
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Yes
B
No
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