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Application Form
Welcome! This is the application form for the Holistic Assessment and Therapies (HAT) Training with Dr. Sara Nasserzadeh. H.A.T is designed for the assessment, diagnosis, treatment and management of psychosexual disorders.
Upon submission, eligible candidates will be contacted for an interview. Thank you for applying.
About the Training
H.A.T is a 10 module training, starting January 2019 and ending December 2019. Each module will take place the first Friday of each month for three hours. There will be no modules delivered in July and August 2019.
The methods of delivery are didactic, experiential and case consultation. All modules will be delivered face-to-face in Dr. Sara's office in Palo Alto. In the case that participants miss a session, relevant materials will be e-mailed to them. Participants should not miss more than two modules in total.

If you have registered before November 1st, you will also receive one hour of individual consultation with Dr. Sara.

Application Form
First Name *
Your answer
Last Name *
Your answer
Pronouns *
Your answer
Date of Birth *
MM/DD/YEAR
Your answer
Occupation *
Your answer
Employer *
Your answer
Licence # (if applicable)
Your answer
I would like to receive Continuing Education (CE) points. I am a: *
AASECT CE points required *
Please note that the CE points acquired through this program could be used towards AASECT’s professional certification; however, it is not the only criteria for being an AASECT-certified therapist or counselor. Please visit www.AASECT.org for further information.
Mailing Address *
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone *
Your answer
E-mail *
Your answer
Preferred method of contact (for administrative purposes and confirming the meetings) *
Required
Ideally, how would your practice be different after participating in the HAT program? *
Your answer
What were your previous trainings in the area of couples therapy, sex therapy, sexual health, sexuality education or the related fields? *
Your answer
Please sign your name here if you consent to e-mail correspondence, which might include personal information: *
Your answer
Preferred method of payment *
Cancellation policy
We know life happens but please notify the office of any need for change or cancellation by January 1st or 50% course fee will not be refunded.
Participation through RAHA
Course meets the qualifications for 30 hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. CEU certificates will be awarded by mail upon full completion of course. Participants must sign in and out in order to receive their certificate. RAHA is an approved CEU provider. Provider # 132334
Venue of the training
Palo Alto CA 94301
Further questions
If you have any further questions please contact Dr. Nasserzadeh’s direct voicemail at (212) 696 6732.
About Dr. Sara
Dr. Nasserzadeh is an Accredited Psychosexual Therapist by the College of Sex and Relationship Therapists in England (COSRT) and a Certified Sexuality Counselor by American Association for Sexuality Educators Counselors and Therapists (AASECT). However, she does not practice in the capacity of a mental health practitioner. By signing this form, you acknowledge the receipt of this information and consent to receive consultations and training from Dr. Nasserzadeh.
www.Sara-Nasserzadeh.com
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Date *
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We will provide light refreshments. Do you have any allergies or preferences?
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