Therapist Certification Systematic Barriers Discount Application

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First name *

Last name *

Professional Suffix (LCSW, MFT, PhD, etc.)
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Email address *

Phone Number (including country code for numbers outside the USA)
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House Number and Street
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City, State, Postal Code

Country *

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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Psychologist

Psychotherapist

Psychiatrist

Licensed Social Worker

Marriage and Family Therapist

Licensed Counselor

Other:

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:

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

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

Tell us about the populations you serve or specialize in (e.g. LGBTQ, BIPOC, homeless, etc.)
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How do you believe becoming a Certified EFT Therapist will benefit yourself and your community?
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Tell us about your financial need.
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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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