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* 1. Name

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* 2. Mailing Address

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* 3. Email address

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* 4. Telephone (office)

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* 5. Telephone (cell)

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* 6. Educational background (degree, field of study, institution issuing the degree):

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* 7. Licensures and Certifications

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* 8. Current occupation (field, employer, position):

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* 9. Which Dual Certification Program are you most interested in applying for (choose one and comment if you'd like to)?

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* 10. Have you completed a BCIA approved didactic training yet? (for Neurofeedback, Biofeedback, or HRV)

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* 11. Applied experience in Mental Performance (aka Sport Psychology) - please list relevant training and experience?

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* 12. Do you own biofeedback equipment? If so, which brand/model? If not, please be sure to have equipment available prior to beginning of mentoring sessions.

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* 13. Do you have access to clients or other willing participants to practice biofeedback and mental performance training?

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* 14. I understand the fee structure and will make a deposit* of $500 upon receiving my first invoice by email. 
*The deposit would be refunded in the unlikely event that the program does not run or if your involvement becomes impossible due to scheduling conflicts.

-Tuition (full amount or 1st installment) will not be due until 15 days prior to commencement of the course.

-I may pay with a check or a credit card (with convenience fee of 3%).

-If tuition is paid in four installments (instead of payment in full), there will be a 5% convenience fee.

-If APA continuing education credits are desired, this will be invoiced seperately ($40).

-The base price for each mentoring program (not including convenience fees or optional APA credits) are as follows:
---CMPC + BCB (General Biofeedback):  $8600
---CMPC + NFB (Neurofeedback):  $8600
---CMPC + HRV-B (Heart Rate Variability):  $7183

For a reminder of any other details, you can view this link.

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