CIIP Enrollment Form-Northwest Institute

CIIP Enrollment Form

Please fill in your details.

First name

Last name

Pronouns

Business Name:

Business Website Address (Published Online)

Email (Published Online)

Phone Number (Published Online)

Office Address (Published Online) N/A if you do not have an office space

How do you see your clients?

Virtually

In-Person

If you take insurance, please list enrolled companies.

Degree Type

License Type

License Number

Year License Obtained

Is your license current?

Yes

Is your license in good standing?

Yes

Upload License

Approximately how many clinical hours do you work a week?

AASECT Member Since

Is your membership current?

Yes

Are you in good standing with AASECT?

Yes

Are you a sex therapy...

Candidate

Certified Member

Supervisor

Are you a sexuality... (or working towards)

Educator

Counselor

Therapist

Were you trained in relational or systemic therapy? (E.g. couples/relational therapy)

Yes

If you were not trained in a formal relational or systemic therapy program, describe the extent of your relational/system therapy training. (e.g. CEU, additional course work)

Upload CV/Resume

Have you taken any medical collaboration courses?

Yes

Have you taken any spiritual intimacy courses?

Yes

TO BECOME AN ASSOCIATE CIIP

You have a minimum of 16 hours of relationship/couple/family therapy training
At minimum: You are a student member of AASECT and are under supervision to become AASECT certified
Unless already certified, you are attending supervision a minimum of one hour a month with an AASECT supervisor
You have taken a Medical Collaboration training (online or in class)
You have taken a minimum of one course in spirtiual intimacy
You have taken one two hour online (or similar) training on justice, diversity, equity, and inclusion as a sexuality professional.
You have taken or are planning to take within the next 12 months the S.A.R.
Licenses in good standing

TO BECOME A CERTIFIED CIIP

Deepen your learning in the above areas
Earn your certification from AASECT
Keep all licenses in good standing

TO BECOME A CIIP SUPERVISOR

Deepen your learning in the above areas
Earn your certification as a Supervisor from AASECT
Keep all licenses in good standing

By signing below, you are indicating that you meet the criteria to become a CIIP. You are also agreeing to your profile being active on the NWIOI website, and will update support@nwioi.com if you need anything changed or updated. You will also alert NWIOI if any infractions are placed against you as a professional.

Your Signature

As a member, you are listed on the NWIOI Website under "Find a Provider."

You get additional member benefits:

Peer-led consultations groups
Free asynchronous courses from NWIOI's Course Catalog
SIPS with CIIPS (coordinated meet & greets, in-person and virtual)
50% discount on live trainings (Not including: Advanced Course, S.A.R.S. or CME Trainings)
Business Coaching