Application - Clinical Meditation and Imagery Date First Name*Last Name*Address*City*State*Zip*Home PhoneMobile PhoneEmail* How did you learn about this program?Professional degree*Do you have a current license or certification?*YesNoStateCurrent place of employmentPlease give us a brief description of the types of people you work with?*What has interested you in attending this program?*What are you hoping for in attending?*Please tell us what your experience has been with imagery and meditation. What is your personal interest and your professional interest?*Tuition for the course is $1,795 and can be paid via PayPal, by mail with a check, or in three installments on a payment plan. Select your preferred payment method below, and we'll follow up with you within 1-2 business days to arrange payment.*PayPalCheckPayment PlanWe will contact you via email using the address you've provided.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.