Reference Form

AAP Membership Chair
Erin McCarthy, LICSW
erinmccarthytherapy@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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Applicant Information