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Psychotherapy Proposal

Student information

Student Name

Phone Number

Therapy Information

Therapist's Name

Therapist Email

Therapist License Number

Therapist License Type

Address

Is your therapist...

NOTE: If your therapist is not licensed or is not a State Registered intern or Psychological Assistant, you need to do your psychotherapy requirement with a licensed therapist or State Registered intern or Psychological Assistant.

If your therapist is an intern, please attach the intern's resume. Are you submitting the intern's resume?

If your therapist is based in a country other than the United States, please provide the equivalent licensure information. If the therapist has no license whatsoever, please attach a resume for the therapist as well as applicable laws around the independent practice of psychotherapy in that country.

Are you submitting information or a resume and applicable laws for a therapist based in a country other than the United states?

Therapeutic format

Therapy Information

Date of first session

Is the date above more than five sessions prior to today's date?

Are you submitting a letter requesting more than five sessions prior to today's date be counted?

Were the hours accrued before enrollment at Meridian?

A request for psychotherapy hours gained prior to enrollment can only be submitted after completing one full year of coursework in the program. If you have not completed one full year of coursework, you do not need to attach a letter to your proposal at this time.

Are you requesting in your letter for hours accrued before enrollment at Meridian to be counted?