MAPS International Therapist Education Program – Alumni Questionnaire – Multidisciplinary Association for Psychedelic Studies

Your Information

Name(Required)

First Last

Email(Required)

Phone

Location of Residence(Required)

City State / Province / Region Country

Birth Year (Required)

What is your primary (most proficient/fluent) language? (Select one)(Required)

Please specify your other language.

If applicable, please select any additional languages in which you are proficient/fluent. (Select all that apply.)

Please specify other additional language.

Your website (if applicable)

How did you first hear about the International Therapist Education Program?(Required)

Please specify other source

Education and Licensure

What is the highest level of education you have completed? (Select one.)(Required)

Please specify other degree

Please indicate your licenses and/or certification. Please select all that apply.(Required)

Please specify other license or certification

In which countries or territories are you licensed/registered?(Required)

Please select any additional licenses or certifications you hold. Please select all that apply.

Please specify other additional license or certification

Experience

As a licensed mental health practitioner, how many TOTAL hours of psychotherapy or counseling have you provided, in any setting?(Required)

Total hours should include psychotherapy and counseling hours gained pre-license in working toward licensure.

How many years have you worked with clients with post-traumatic stress disorder (PTSD)?(Required)

Please describe the setting where you spend the majority of your time seeing and treating clients.

Please specify other setting type

Do you have experience providing clinical supervision? If yes, please describe.

Which marginalized communities do you currently work with? Please select all that apply.(Required)

If you serve other marginalized communities, please describe the populations you work with.

Demographic Questions

MAPS is committed to providing an inclusive education program for a diverse group of clinicians and accessible and culturally relevant education to diverse populations. While the following questions explore individual categories of identity separately, we recognize these categories and lists are not exhaustive. We value every applicant’s complexity, acknowledging you each hold many identities, and each of your multiple identities interact and intersect in unique ways. Your responses will help us evaluate our program, policies, and recruitment strategies. If you have any questions or concerns, please let us know!

With which racial or ethnic group(s) do you identify? Please select all that apply.(Required)

White / Caucasian / European

Black or African descent

Asian

Hispanic / Latino / Spanish origin

Middle Eastern or North African

Indigenous / Native American / First Nations

Pacific Islander

Prefer not to say

Some other race, ethnicity, or origin

Please describe your race, ethnicity, or origin in your own words.

With which gender do you most identify?(Required)

Do you identify as transgender?(Required)

Do any of the following identities apply to you (Asexual, Bisexual, Fluid, Gay, Lesbian, Pansexual, Queer)?(Required)

Do you have a disability or impairment?(Required)

If you have a disability or impairment and feel comfortable sharing it, please describe it here.

Are you an active member or veteran of the military?(Required)

Privacy Information

MAPS respects your privacy. The information you submit on this form will be respectfully reviewed and stored by MAPS in order to improve our programs and communicate with you. Your information will be saved in a database maintained by MAPS and may be stored for ten years or longer. Your information will not be sold or distributed. In the rare event of a data breach where identifying information is accessed by an unauthorized person, MAPS will make every effort to notify all applicants who may be affected. If at any time you would like your data removed from our records, please submit a request to education@maps.org. You can view MAPS’ privacy policy here: maps.org/privacy.

Privacy Confirmation(Required)

I understand and agree

International Therapist Education Program

Alumni Questionnaire

Your Information

Education and Licensure

Experience

Demographic Questions

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