Renewal Application

Certification Renewal Application

If you are already certified, this form is to be used for renewal. You can also download the form in PDF format if desired.

"*" indicates required fields

Name*

Degree*

Professional License type*

Licensing State and #*

Work address*

Email*

Phone*

Place of employment or practice*

Highest level of education attained

Years of experience as a licensed practitioner

Institution awarding highest degree

Name of Consultant used as well as the date of original Certification

Name of Consultant/Expert and Date of 1 hour of consultation for renewal

Please use Session Tracking Form to document the 100 hours required for recertification

Certification Renewal Fee*

Two year renewal requires:

100 documented client hours.
$100 Fee.
Required One (1) hour of Consultation with a Brainspotting Consultant/ Expert hours.

Price:

Total

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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