Supervisor Certification Discount Application

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

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

Question Title

* 4. Email Address

Question Title

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

Question Title

* 6. House Number and Street

Question Title

* 7. City, State, Postal Code

Question Title

* 8. Country

Question Title

* 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:

Psychologist

Psychotherapist

Psychiatrist

Licensed Social Worker

Marriage and Family Therapist

Licensed Counselor

Other Licensed Mental Health Professional (please specify):

Question Title

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

A person of color

Indigenous

White

Cisgender (the sex I was assigned at birth is the sex I identify as)

Non-Binary, Transgender, Intersex, gender-fluid, agender or other

Gay, Lesbian, Bisexual, Asexual, Pansexual

Heterosexual

Immigrant

Disabled

I experience oppression as a result of a physical attribute: my size, my abilities, the way I look or sound, other

I live in relative poverty with a regular sense of financial insecurity and/or physical safety insecurity

I live in a middle class or wealthy environment, but I struggle financially and have a sense of financial and/or physical safety insecurity

Other (please specify)

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 15. Tell us about your financial need.

Question Title

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