Recertification Session Documentation Form

Renewal Documentation Form

This form is to be used for recertification/renewal. You can also download the form in PDF format if desired.

After this form is filled out, you will receive a PDF copy by email to use on the renewal application form.

"*" indicates required fields

Practitioner’s Name*

Email*

Consultant's Name*

Please list details of a session using one of the following frames and submit this document with your consultant’s recertification report. Please alter the recipient’s name or put initials for confidentiality purposes.

Frame Set-up used: Outside Window

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Inside Window

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Gazespotting

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Body Resource Model

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Outside-Inside Window

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Rolling

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Z axis & Vergence

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: One Eye Brainspotting

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Frame Set-up used: Advanced Resource Model

Date*

Anonymous Brainspotting Recipient Identifier*

Presenting issue*

Briefly describe what motivated you to choose this frame set-up*

Briefly describe the recipient’s process*

Briefly describe your experience of the process (attunement, limbic countertransference, tail of the comet, etc.)*

Practitioner Signature*

Date*

Directory

Recertification Session Documentation Form

Renewal Documentation Form

Frame Set-up used: Outside Window

Frame Set-up used: Inside Window

Frame Set-up used: Gazespotting

Frame Set-up used: Body Resource Model

Frame Set-up used: Outside-Inside Window

Frame Set-up used: Rolling

Frame Set-up used: Z axis & Vergence

Frame Set-up used: One Eye Brainspotting

Frame Set-up used: Advanced Resource Model

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