Psychedelic-Assisted Psychotherapy - Register a new facility - College of Physicians & Surgeons of Alberta

Before CPSA can accredit your facility to provide psychedelic-assisted psychotherapy, we first need to perform an assessment.

Please complete this form to register for an assessment. You’ll need to provide information about:

your facility’s owner, location, hours of operation and records keeping
personnel, including the facility’s medical director
other physicians providing care, personnel administering psychedelic drugs and monitoring patients, and personnel providing psychotherapy
descriptions of services provided, including psychedelic drugs currently in use

Once we’ve received your submission, we’ll be in touch to provide details about next steps.

General Facility Information
Facility Name*
Owner(s)*
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Fax
Email*
Enter Email Confirm Email
Alberta Mental Health & Addictions licence number
Days/hours of operation
What are the routine days of operation?*
What are the routine hours of operation?*
Integrated electronic health records
Does your facility use an EMR system?*
- Yes
- No
Does your facility upload reports into Netcare?*
- Yes
- No
- In progress
Personnel
Medical Director
Name*
First Last
CPSA registration number*
Speciality*
Phone*
Email*
Enter Email Confirm Email
Facility contact
Name*
First Last
Phone*
Email*
Enter Email Confirm Email
Financial contact (if applicable)
Name
First Last
Phone
Email
Enter Email Confirm Email
Other personnel
Other physicians providing care
Click + to add a row
Name CPSA registration # FT/PT/Casual
Personnel administering psychedelic drugs and monitoring patients*
Click + to add a row
Name Qualification (e.g., RPN, ACP) Respective college (e.g., CARNA, CRPNA) Registration # FT/PT/Casual
Personnel providing psychotherapy*
Click + to add a row
Name Qualification (e.g., RPN, Psych) Respective college (e.g., CARNA, CRPNA) Registration # FT/PT/Casual
Services
Describe the services provided in your facility:*
Click + to add a row
Psychedelic drug(s) currently in use # of patients seen each month
Medical Director's Signature
Medical Director's Name*
First Last
Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
Checking this box will act as your signature:*
I have reviewed the information in this form and confirm it is accurate.
Privacy Notice: This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act. CPSA collects, uses and/or discloses your personal information with your consent or as authorized or required by law and in accordance with our Privacy Statement. We collect and use your personal information in order to support the business of CPSA, specifically to protect the public and guide and regulate our members.
Email
This field is for validation purposes and should be left unchanged.

Questions about filling out this form?

Toll-free: 1-800-561-3899 (in Canada)
Fax: 780-424-5859

Name*
First Last
Email*
Enter Email Confirm Email
Which accreditation program would you like to contact?*
Your Message*
Phone
This field is for validation purposes and should be left unchanged.

Psychedelic-Assisted Psychotherapy – Register a new facility

General Facility Information

Days/hours of operation

Integrated electronic health records

Personnel

Medical Director

Facility contact

Financial contact (if applicable)

Other personnel

Services

Medical Director's Signature

Questions about filling out this form?

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Name	Qualification (e.g., RPN, ACP)	Respective college (e.g., CARNA, CRPNA)	Registration #	FT/PT/Casual

Name	Qualification (e.g., RPN, Psych)	Respective college (e.g., CARNA, CRPNA)	Registration #	FT/PT/Casual

Psychedelic drug(s) currently in use	# of patients seen each month