Clinician Application

This application for clinician's looking to incorporate elements of RSB into their one-on-one visits with clients. This training IS NOT a part of our affiliate program and doesn't come with the benefits of being an RSB affiliate program.

Fields marked with an * are required.

First Name *

Last Name *

Address Line 1 *

Address Line 2 *

City *

State *

Postal Code *

Country *

Email *

Phone *

Organization *

Clinician Background information *

Please list your education information below.

Training Dates *

Please select which training date you'd like to attend.

November 7-8, 2024 - Indianapolis, IN

January 16-17, 2025 Indianapolis, IN

April 24-25, 2025 Indianapolis, IN

June 5-6, 2025 Indianapolis, IN

July 17-18, 2025 Indianapolis, IN

September 25-26, 2025 Indianapolis, IN

November 6-7, 2025 Indianapolis, IN

Certification Upload *

Please upload your certification for review.

20MB max

Please verify that you have checked the “I'm not a robot” checkbox.