Reference Form | American Academy of Psychotherapists

AAP Membership Chair
Nelia H. Rivers, L.C.S.W.
736 Darlington Circle NE
Atlanta, Georgia 30305
404-261-8461
neliarivers@gmail.com

The person listed below is applying for membership in the American Academy of Psychotherapists and has listed you as a reference. To help us evaluate this applicant for membership, we would appreciate your reply to the following questions. The applicant has agreed this information may be released and your answers will be considered confidential. If you have been the applicants' therapist you need only to validate the number of therapy hours that the applicant spent with you.

Your Name*

First Last

Your Email Address*

Your Phone Number*

Type of Phone:*

Work
Home
Mobile

Your Discipline*

Relationship to Applicant*

Therapist
Supervisor
Colleague

Applicant Information

Name of Applicant*

First Last

How many hours has the applicant spent in therapy with you?

Group	Individual

How many hours has the applicant spent in supervision with you?

Group	Individual

How long have you known the applicant and in what capacity?

As a supervisor, therapist or colleague what are your impressions of the applicant as a therapist?

In your opinion, is the applicant qualified for the independent practice of psychotherapy in his/her discipline?*

Yes
No
I don't know

If you are a current or former AAP member, do you recommend this applicant for membership?*

Yes
No
Never a member

Signature*

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