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* 1. First name

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* 2. Last name

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* 3. Professional Suffix (LCSW, MFT, PhD, etc.)

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* 4. Email Address

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* 5. Phone Number (including country code for numbers outside the USA)

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* 6. House Number and Street

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* 7. City, State, Postal Code

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* 8. Country

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* 9. I represent and warrant that I am a mental health care professional in the field of psychotherapy or a similar profession, and that I accept and comply with all related professional and legal responsibilities. Specifically, I am a:

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* 10. Please tell us about how you identify - check all that you feel are most relevant (optional)

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* 11. What else would you like us to know about your identity? (Please specify.) (optional)

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* 12. Tell us about your practice and area of focus (e.g. individuals, couples, families, veterans, prisoners, etc.)

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* 13. Tell us about the populations you serve or specialize in (e.g. LGBTQ, BIPOC, homeless, etc.)

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* 14. How do you believe becoming a Certified EFT Therapist will benefit yourself and your community?

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* 15. Tell us about your financial need.

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* 16. Is there any other information that you believe would be relevant in your application for an EFT Therapist Certification application fee discount? (optional)

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