Forms

Licensure Documentation Form

Name*
First Last
Email*
Emergency Contact Name & Phone Number*
Please list the location and date for the event you are attending. If virtual you can just type “virtual”*
License Type (Select one)*
- LCSW
- LMFT
- PsyD
- PhD
License Jurisdiction (state, province, or country)*
License Number*
Upload Independent Professional License MUST INCLUDE EXPIRATION DATE (Do not upload professional insurance or your driver’s license)*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Upload a copy of your CURRENT license, certification, or the equivalent, as a mental health professional per the guidelines of your state, province, or country. If you don't have a digital copy of your license, you may either scan or photograph it. Click here if you need additional instructions. *Please make sure your file size is no larger than 10MB.