Psychotherapy Final Hours Form

Psychotherapy Final Hours Form

This form will be routed to the student and then to the Academics Office at The Seattle School of Theology and Psychology. STUDENTS: please review the form when it is sent to you via email, sign, and submit. For questions please email academics@theseattleschool.edu
To be filled out by the therapist.

Note: No case notes, diagnosis, etc. shall be shared with the school by the therapist. Only this completed form is required.
Student Name*

First NameLast Name
Student Email Address*
example@example.com
Therapist Name*

First NameLast Name
Therapist Email Address*
example@example.com
Number of hours completed by the student.*
Please note: This form must demonstrate at least 40 hours completed within an 18-month period.
Time frame (e.g., January 3, 2021-June 3, 2022)*
Please note: This form must demonstrate at least 40 hours completed within an 18-month period.
Therapist Information
Therapist Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Therapist Phone Number*
Please enter a valid phone number.
Type of License and License Number*
e.g. LMHC ######
Date License Issued*

MonthDayYear
Date
Date License Expires*

MonthDayYear
Date
Graduate degree, awarding institution, and year awarded*
Link to Policy: https://theseattleschool.edu/wp-content/uploads/2023/09/2023-Psychotherapy-Requirement-Policy.pdf
I have received and reviewed The Seattle School Psychotherapy Requirement Policy (Rev. 10/2021) ("Policy"), and I hereby certify that the above named student has completed a minimum of 40 hours of psychotherapy within an 18 month period (per the dates named in question 3 above). The psychotherapy provided to the above named student satisfies the requirements of section 1 of the Policy. I satisfy the criteria set forth in Section 2 of the Policy.*

I agree
Signature*

Clear
Should be Empty:

Psychotherapy Final Hours Form

To be filled out by the therapist.

Therapist Information