Enrollment Information

Finalize your enrollment by completing this form.

Full Name

What are your preferred pronouns?

Address

Address Line 2

City

State/Province

Zip Code

Country

Phone Number

Were you referred by a current AIP Certified Coach? If so, please provide their name.

Do you have professional liability insurance?

Yes

No, because I am covered under my employer's liability insurance

No, because I have not yet starting practicing

No, because liability insurance is not available in my country

Do you have a license or certification (we call this your "base certification") that allows you to work directly with patients or clients?

Yes

What is your "base certification"?

How long have you been practicing with your "base certification"?

If you do not have a "base certification," please provide additional information to explain what qualifies you to work with patients or clients.

On a scale of 1-10 with 10 being expert-level, how would you rate your understanding of AIP going into this program?

Is there any other relevant info you'd like to share with us?

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