IECMH CONSULTATION CERTIFICATE: LETTER OF INTENT

IECMH CONSULTATION CERTIFICATE: LETTER OF INTENT

Thrive Center at Georgetown University
This Letter of Intent expresses our organization's interest in enrolling staff in the new practical certificate in Infant & Early Childhood Mental Health Consultation, a competency-based professional development program.

The program is 100% virtual with 2-3 hours a week of self paced work and a 90 minute live class (over 10 time slots each week for classes).

We have a few last spaces available in June and 250 more spaces in October.

By filling out this form before June, you are securing our founding members discounted price of $2,500.

NOTE: Individuals can also sign up for the program independently. Just leave the organization field blank. Thank you!
Organization Name (leave blank if signing up as individual):
State
Contact Person:
Contact Title:
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Which cohort are you registering people for?

Individuals to be Enrolled: NOTE: pathway (A) is for those with mental health education/training, (B) is for those from early child education background

Rows	Full Name	Title/Position	Email	Pathway
1
2
3
4
5

(Additional sheet below if enrolling more than 5 people)
Statement of Intent as a Founding Cohort Organization

1. We intend to enroll the above individuals in the June 2026 Thrive Center IECMHC Certificate Program.

2. We understand that payment of $2,500 per person is required before the program start date to confirm enrollment.

3. We are willing to participate in a brief reference call with third parties (e.g., iinstructors partners) to share our interest in this program, if requested.

4. Upon successful completion of program, if it meets or exceeds our expectations, we agree to provide a public testimonial that may be used in marketing materials.

Terms

Next Steps: Upon signing, you will receive enrollment confirmation and payment instructions.

THRIVE
CENTER

for Children,
Families, and
Communities
Authorized Signature
Signature:
Date:

MonthDayYear
Date
Printed Name:
Title:
Questions? Contact us at si436@georgetown.edu | Return signed LOI to the same address

Additional Individuals to be Enrolled

Rows	Full Name	Title/Position	Email	Pathway
1
2
3
4
5
6
7
8
9
10

Should be Empty:

IECMH CONSULTATION CERTIFICATE: LETTER OF INTENT

Authorized Signature