Enrollment Form

Enrollment Form

To enroll in AGI's Professional Certification Training program, please provide the following information below.

For the forms you are required to Read, Agree, Sign and Upload, click here.

First Name *

Last Name *

Degree(s) *

If not applicable, type "None".

Occupation(s) *

If not applicable, type "None".

Primary Email *

Secondary 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: *

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 for Guided Imagery's Student Agreement.

Upload your signed Student Contract. *no file selected

Print, sign, scan, and upload your Student Contract 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.

no file selected

Print, sign, scan, and upload your Promissary Note 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).

no file selected

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.

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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.

no file selected

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

Subscribe to AGI's email list?

Join AGI's discussion forum?

I'm NOT a Robot: *

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