Psychotherapy Verification: Initial Hours

Psychotherapy Verification: Initial Hours

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*
example@example.com
Therapist Name*

First NameLast Name
Therapist Email*
example@example.com
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 Held and License Number*
e.g. LMHC #######
Date of Therapist's License Issued*

MonthDayYear
Date
Date of Therapist's License Expiration*

MonthDayYear
Date
Therapist's Graduate Degree, Awarding Institution, and Year Awarded*
Number of hours completed by student to date*
Time Frame *
start date to current date

Therapist Attestation
Information on therapist requirements may be found in Section 2 of The Seattle School Psychotherapy Requirement Policy: https://theseattleschool.edu/wp-content/uploads/2023/09/2023-Psychotherapy-Requirement-Policy.pdf

Please Note: Therapy can be provided either in-state or across state lines where it is legal for the provider to do so. It is the responsibility of the provider to determine their eligibility to provide services across state-lines.
I hold a Master's or Doctoral degree in a mental health field or a degree as a Doctor of Medicine (M.D., in the case of a psychiatrist).*

YesNo
I am licensed by the state in which services are rendered as a Psychologist, Marriage & Family Therapist, Mental Health Counselor, Clinical Social Worker, Advanced Clinical Social Worker or Psychologist, or licensed to practice medicine in the case of a psychiatrist.*

YesNo
I hold the following type of license:*

full license (LMHC, LMC, LMFT, or equivalent).associate license (LMHCA, or equivalent pre-license credential).
I understand that per section 2 of the Policy linked above, the student may see an Associate (or other state term for a pre-license credential) licensed provider in the following conditions: (1) The psychotherapist is licensed as an associate (or equivalent) for over 24 months since the 40 required hours began AND (2) the therapist’s supervisor signs the Initial Hours form along with the therapist indicating their agreement and understanding of the policy.

Yes
I have been licensed as an associate (or equivalent) for over 24 months since the 40 required hours began.

YesNo
Please upload a signed letter from your supervisor indicating that you (the therapist) are in good standing to take on this work with the student, and that they will commit to supporting the work throughout the completion of the 40 hours.

Cancelof

I have received and reviewed The Seattle School Psychotherapy Requirement Policy (Rev. 03/2023, linked above) ("Policy"), and I hereby Certify that the above named student has completed the amount of hours of psychotherapy named in question two (above) with the time framed named in question three (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 Verification: Initial Hours

To be filled out by the therapist.

Therapist Attestation