EMDR Consultation Documentation Request Form

PLEASE READ BEFORE COMPLETING THIS FORM

This form sends ONE request to Sam to personally prepare consolidated professional documentation of your applicable EMDR consultation hours.
This form does NOT automatically generate or resend an attendance confirmation, letter, or other document.
Submit this form ONE TIME only. Do not submit a separate form for each consultation appointment or group. Below, you will list ALL applicable consultation hours completed with Sam for the credential you are pursuing.
Standard processing may take up to 30 days. Submitting duplicate forms or sending additional requests does not expedite processing.
See my website for options to expedite your documentation.

Today's Date (dd/mm/yyyy format)

Name

First NameLast Name

Email

example@example.com

Pronouns for the letter.

What credential are you applying for?

List ALL consultation hours completed with Sam that should be included in this ONE consolidated document.*

For each consultation, include the date, duration, and format (individual or group).

Example:
1/1/26, 2 hrs, group
1/4/26, 1 hr, individual

Do not submit separate forms for separate consultation dates. Only include hours applicable to the credential identified above.

I understand that this form does not automatically generate or resend a document or attendance confirmation.

I understand that I am requesting one consolidated document covering all applicable consultation hours completed with Sam.

I have included all applicable consultation dates and hours in this one request.

I understand that I should not submit additional forms for individual consultation dates or groups.

I understand that standard processing may take 30+ days and duplicate submissions do not expedite my request.

I attest that the information provided above is accurate. I understand that this request is for verification of consultation hours only and does not include a recommendation for the credential I am pursuing.