Nominate Your Therapist

Your therapist works hard, say thanks by nominating them for an award below!

Your Name

First Name

Last Name

Your Contact Info

email and/or phone number

Relationship to Nominee?

(client, supervisor, coworker, family/friend, etc.)

Nominee's Name

First Name

Last Name

Nominee's Email

Nominee's Phone Number

(###)

###

####

Nominee's Clinic/Place of Employment

Nominee's Website/Social Media (if applicable)

http://

How has this person impacted you? Why do they deserve an award?

We will be awarding up to 3-5 therapists with an award for Mental Health Provider of the year - you're recommendation and nomination will assist us in that process.

Write a brief "Thank You Note" to the Nominee. (optional)

We will be notifying the nominee that they have been nominated and would like to include a nice note from the person they were nominated and the reason they were nominated.

Would you like to remain anonymous?

No

Yes

How did you hear about #THANKYOURTHERAPIST?

Social Media

My Therapist's Office

Ascendant Tracker's Emails

Poster Announcement

Other