Bcia Mentoring For Neurofeedback Certification Time/activities Log Form

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BCIA Mentoring for Neurofeedback Certification
Time/Activities Log Form
Applicant _____________________________________
Mentor________________________________________ Certification # _________________
The log below lists the specific dates, times and descriptions of mentoring activities being
presented for certification.
Date
25
Description of Mentoring
10
100
10 Case
Contact
Activities
Personal
Patient/Client
Conferences
Hours
Sessions
Sessions
Contact Hours Completed with Mentor: ________ Hours
I attest that the mentoring hours listed above are accurate.
BCIA Mentor Signature _________________________________ Date: ________________
Applicant Signature _________________________________ Date: ________________
Note: More than one mentor may be used. Please submit this form for each mentor.

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