Date

Consulting Supervisor’s Name:

Consulting Supervisor’s TMAATT Certification Number:

Consulting Supervisor’s email:

Scholar’s Name:

First Name

Last Name

Scholar’s Title:

Scholar’s therapist license number or coaching certification number:

Scholar’s Certification Designations (MBATT or MBRC):

Scholar’s Email Address:

Scholar’s Phone Number:

(###)

###

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Scholar’s Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has the scholar completed 6 hours of consulting supervision within the certification expiration year?

Has the scholar met the TMAATT standards of certification?

Is the scholar operating legally and ethically?

Is the scholar currently, or within the last two years, faced ethical, or professional challenges that need to be disclosed (i.e. arrest, license or certification suspension or revocation, other legal or ethical complaints or issues)? If so, please explain here:

What areas is the scholar excelling in?

What areas is the scholar in need of support (if applicable)?:

Other comments:

Renewal Issue Date:

Supervisor’s Signature (Initials):