Pelvic Health Sex Counseling Application

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Please take some time to give us enough information about you to let us know why you're interested in this program! All levels of experience are welcome to apply.

Please refer to www.pelvicsexcounseling.com or email courses@pelvicguru.com for further details about the program including dates and fees.

Email *

What is your first name? *

What is your last name?

What are your pronouns? *

Are you of Hispanic, Latino, or Spanish origin? *

Yes

How would you describe yourself? *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Hispanic/Latino

Don't know

Prefer not to answer

What type of licensed medical or allied health professional are you? Please include the state, country, and license number. *

Are you interested in becoming AASECT certified? *

Yes

I'm already AASECT certified

What experience do you have with pelvic health and/or sexual health? *

What changes would you like to make in your profession and community regarding pelvic and sexual health? *

How do you see the knowledge you gain in this program fitting into your career? *

What are your goals for this certificate program? *

Where did you hear about this program?

Please feel free to add any additional thoughts or comments for consideration.

A copy of your responses will be emailed to the address you provided.

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