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Psychotherapy Verification Form Request

Submit this form to request that the Verification form be sent via DocuSign to you and your therapist. This form must be submitted for each therapist with whom you completed hours

Student's Name

*

*

Student's Email

*

Degree Program

*

Therapist's Name

*

*

Therapist's Email

*

Has your psychotherapy proposal for this therapist been approved?

*

If no, the Psychotherapy Proposal must be submitted and approved prior to the submission of this form