NATouch LA Application 2019
RequiredRequired Question(s)
This professional training is open to all mental health professionals, psychotherapists, psychologists, medical doctors, supervised registered interns, social workers, bodywork practitioners, nurses, and life coaches. Applications are approved on a case-by-case basis. After receiving your application and registration, we may call you for a short conversation. This will help insure that our training is a good fit for your professional needs. Please note that participants must carry malpractice insurance. 
 
Required 1.
Please enter the information indicated below.

First Name:
Last Name:
Job Title:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:
Country:

Required 2.
What is the best way to reach you?

Email
Work Phone
Cell Phone
Other  
  • Comment:

  • 500 characters left.
Required 3.
Degrees / Licenses / Certifications 
 

350 characters left.
Required 4.
Please describe any relevant psychological trainings. 
 

1000 characters left.
Required 5.
Do you have training in somatic psychotherapy or touch for therapeutic purposes? 
 

1000 characters left.
Required 6.
What are your areas of specialization? 
 

350 characters left.
Required 7.
Do you have training in any other bodywork or movement modality? 
 

1000 characters left.
Required 8.
What is your professional practice setting? 
 

50 characters left.
Required 9.
Please tell us about your interest in the NeuroAffective Touch® training and how you think it will benefit you?
 

1000 characters left.
Required 10.
Do you have a mindfulness, meditation, or yoga practice? If you do. please tell us about it.
 

350 characters left.
Required 11.
How did you hear about the NeuroAffective Touch® training? 
 

350 characters left.
Required 12.
Do you have a massage table that you can bring to the trainings (not required)? 
Yes
No
13.
Is there anything else you would like to tell us that would help us know you better?
 

1000 characters left.

REGISTRATION

Now that you have filled in your application, please click the "Finish" button below for the registration link.

Questions? Please contact: victor@neuroaffectivetouch.com 

The NeuroAffective Touch® Institute is neither a regulatory nor licensing organization and therefore not sanctioned to certify, license, or otherwise bestow the legal authorization to practice as a mental health professional.
The NeuroAffective Touch® Institute reserves the right to approve or deny any application, and/or accept or reject the participation of any person in its sole discretion, with or without cause, and in accordance with its policies and the law.