Application 2019

KRIYA Conference 2019 is Sold Out!
We are accepting applications for the Waitlist only.

Please go to the main page for KRIYA Conference 2019 for detailed information about this event. Then, if you would like to attend, please complete the application form below. This form is required for all conference attendees, speakers, and staff (crew).

First Name*

Last Name*

Occupation (Psychiatrist / Psychologist / Therapist / Researcher / etc.)

Clinical Degree (M.D. / D.O. / Ph.D. / Psy. D / M.F.T. / L.C.S.W. / P.N.P. / etc.)

State & License Number

City (where your office is located)

State (or country if you live outside of the U.S.A.)

Email Address*

Phone Number(s)*

Clinic or business name

Website

University or Institutional Affiliation (Are you a professor or a student? Full-time or part-time?)

How many patients have you personally treated with ketamine for a psychiatric or psychological reason (since you began working with ketamine)?

Please describe your work or your interest in therapeutic ketamine.
– If you have been working with ketamine, please describe the route of administration that you prefer, your dosing strategy, and the kinds of patients that you treat.
– If you have not worked with ketamine yet, please describe your interest in this conference. Please also include detailed information on any lectures or workshops about ketamine that you have attended.

If you have any interest or experience in working with visionary medicines other than ketamine, please include that information here.

Please briefly describe your clinical training and interests.
– If you are a psychotherapist, what style of therapy do you practice?

KRIYA Institute would like to have more demographic diversity at KRIYA Conference. If you are a member of an under-seen or under-served group, please include that information here (including – but not limited to – people of color, queer people, people with disabilities, etc.)

This entire conference will be recorded (audio and video) by the event staff. These recordings may be made available to the public in the future.*

I Agree
I Do Not Agree

Attendees may not make their own audio or video recordings at the conference. Still photos are allowed (and encouraged).*

I Agree
I Do Not Agree

Do you require a Service Animal at this event?*

Are you planning to apply for a speaker slot?

READ THIS: On the next screen, you will be asked to pre-authorize a future payment on your credit card for up to $895. Your credit card will not be charged until you are offered a confirmed seat. If you apply for a speaker slot, and your talk is selected, your card will be charged $395 instead.

Conference Fee:

$895.00 – KRIYA Conference 2019
$0.00 – KRIYA Crew

Press the “Continue” button below to send your registration information to KRIYA Institute and go to the secure payment window.