INTERNATIONAL INSTITUTE FOR TRAUMA & ADDICTION PROFESSIONALS
P.O. Box 2112
Carefree, AZ 85377
…Setting the standards in education for addiction professionals
CERTIFIED SEX ADDICTION THERAPIST (CSAT®)
ASSOCIATE SEX ADDICTION THERAPIST (ASAT®)
TRAINING APPLICATION FORM FOR CALGARY
This form must be completed and submitted prior to any aspect of the certification process.
After opening the file in Word format, select "save" and name the file; complete the form in its entirety (note the blanks on the form
expand as needed); re-save, and; email directly to info@iitap.com.
SECTION I: IDENTIFYING INFORMATION
Complete the below section as you would like it to appear on certificates, the IITAP website, etc. Please note that if
any of your contact information changes, it is your responsibility to notify IITAP.
Legal Name(Include
Credentials)
Preferred Name:
Check here if this is also the name you would prefer for the
website.
Former Name(s) such as
maiden name:
Home Address:
City:
Postal
Code:
Province:
Home Phone:
Cell Phone
Agency/Employer #1:
Non Profit Agency? Yes / No – If yes, please see note below
Work Address #1:
Postal
Code
#1:
City #1:
Province #1:
Office Phone #1:
Fax #1:
Email Address #1:
Website Address #1:
Agency/Employer #2:
Non Profit Agency? Yes / No – If yes, please see note below
Work Address #2:
Postal
Code
#2:
City #2:
Province #2:
Office Phone #2:
Fax #2:
Email Address #2:
Website Address #2:
Non-profit employees need to submit a letter of support from their
supervisor/executive director indicating how the training will benefit their
agency.
(480)575-6853 Office

(480)595-4753 Fax

Info@IITAP.com

www.IITAP.com

Rev. 8/19/11

Page 1 of 5
INTERNATIONAL INSTITUTE FOR TRAUMA & ADDICTION PROFESSIONALS
P.O. Box 2112
Carefree, AZ 85377
…Setting the standards in education for addiction professionals
CERTIFIED SEX ADDICTION THERAPIST (CSAT®)
ASSOCIATE SEX ADDICTION THERAPIST (ASAT®)
TRAINING APPLICATION FORM FOR CALGARY
SECTION II: EDUCATION
What is your current level of education?
Bachelors
Masters
Please provide copy of your degree and official
transcripts
PhD
Other
M.D.
DATE DEGREE
CONFERRED
NATIONALLY ACCREDITED ACADEMIC INSTITUTION
PROVIDE COPY OF
DIPLOMA(S)
SECTION III: WORKSHOPS ATTENDED

Yes
Have you attended any of Dr. Carnes’ or other sex
addiction workshops? If yes, please list them below with
the date and location.
WORKSHOP
No
DATE
LOCATION
DATE
PROVIDE COPY OF
LICENSE(S)
SECTION IV: LICENSES & CERTIFICATIONS

What professional certifications/licenses do you currently hold?
LICENSE / CERTIFICATION
(480)575-6853 Office

(480)595-4753 Fax

Info@IITAP.com

www.IITAP.com

Rev. 8/19/11

Page 2 of 5
INTERNATIONAL INSTITUTE FOR TRAUMA & ADDICTION PROFESSIONALS
P.O. Box 2112
Carefree, AZ 85377
…Setting the standards in education for addiction professionals
CERTIFIED SEX ADDICTION THERAPIST (CSAT®)
ASSOCIATE SEX ADDICTION THERAPIST (ASAT®)
TRAINING APPLICATION FORM FOR CALGARY

Have you ever had a certification/license suspended, revoked, or ever
received disciplinary action?

If yes, please explain:
Yes
No
o
SECTION V: PROFESSIONAL ORGANIZATIONS & MEMBERSHIPS
Please list any memberships in professional organizations, committees, societies, boards, clubs, etc., including types of membership
(i.e., professional or associate), status (active or inactive), and dates of membership.
ASSOCIATION / SOCIETY
TYPE
DATES
STATUS
Professional
Associate
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Active
Inactive
Professional
Associate
Professional
Associate
Professional
Associate
Professional
Associate
SECTION VI: CLINICAL EXPERIENCE
What is your clinical experience and what are your clinical specialties?





(480)575-6853 Office

(480)595-4753 Fax

Info@IITAP.com

www.IITAP.com

Rev. 8/19/11

Page 3 of 5
INTERNATIONAL INSTITUTE FOR TRAUMA & ADDICTION PROFESSIONALS
P.O. Box 2112
Carefree, AZ 85377
…Setting the standards in education for addiction professionals
CERTIFIED SEX ADDICTION THERAPIST (CSAT®)
ASSOCIATE SEX ADDICTION THERAPIST (ASAT®)
TRAINING APPLICATION FORM FOR CALGARY
Please provide an updated Curriculum Vitae/Resume:
Yes
No
Yes
No
SECTION VII: SUPERVISION
Do you currently receive clinical supervision?
Supervisor Name:
Address:
City:
Province:
Phone:
Fax:
Postal
Code:
Email:
SECTION VIII: HELP US GET TO KNOW YOU…
How did you hear about IITAP and the CSAT® Program?

Provide reasons why you want to become a CSAT®:




What do you believe you can offer to both your community and the CSAT® community?




(480)575-6853 Office

(480)595-4753 Fax

Info@IITAP.com

www.IITAP.com

Rev. 8/19/11

Page 4 of 5
INTERNATIONAL INSTITUTE FOR TRAUMA & ADDICTION PROFESSIONALS
P.O. Box 2112
Carefree, AZ 85377
…Setting the standards in education for addiction professionals
CERTIFIED SEX ADDICTION THERAPIST (CSAT®)
ASSOCIATE SEX ADDICTION THERAPIST (ASAT®)
TRAINING APPLICATION FORM FOR CALGARY
SECTION IX: REQUIRED DOCUMENTATION
Make sure you have included the below items with your application:

Application

Copy of current license/certificate

Copy of current malpractice insurance certificate (if covered by an organization- provide a copy of
organization’s insurance)

Degrees - Copies of Diplomas (Digital photo can be e-mailed to info@iitap.com)

Official Transcripts (Sealed transcripts from the University sent directly to IITAP.)

Current CV/Resume
Norlien Foundation has graciously offered scholarships for Alberta participants. The availability of
scholarship funds will be based upon a commitment to attend all four training modules and
complete the requirements to obtain and maintain your ASAT®/CSAT® certification, and will
incorporate the training information and materials into your work with clients. If you agree to
these terms, please initial here._______
NOTE: Please save this completed form and send directly to IITAP at either info@iitap.com. The form may also be faxed to 480-5954753.
(480)575-6853 Office

(480)595-4753 Fax

Info@IITAP.com

www.IITAP.com

Rev. 8/19/11

Page 5 of 5