Associate – Application

    Applicant Information

    Your Name
    (Mi)
    (Last)
    Affliation
    Position Title
    Address
    City
    State
    Zip
    Work Phone
    Home
    Cell
    Email
    SS#?(only last 4 digits)
    Highest MH Degree
    Primary MH Credential

    Please include a copy of your state mental health professional license indicating that you are legally allowed to independently provide clinical mental health services.

    License (LCSW, LPC, etc)
    Licensing Board
    License #
    Issued (mm/dd/yy)
    Expires (mm/dd/yy)


    Associate Application

    Upload copies of certificates for:
    • Reaching Children Through Play Therapy
    • Webinar: The Symbolic Meaning of Toys in Experiential Play Therapy (EPT)®
    • Webinar: The Symbolic Meanings of Animals, Roles, and Environments in Experiential Play Therapy (EPT)®
    • Webinar: Testing for Protection and Dependency Stage in in Experiential Play Therapy (EPT)®
    • Currently in supervision with an EPT/S

    You must enter your name and email address to upload documents.

    You will have the opportunity to upload multiple documents at once, so get organized before beginning and save yourself time. Do NOT upload .zip files, they will be rejected. Upload individual files.

    Please rename your documents to conform to the following naming convention:

    • Document Name – Date (month,day,year)
    • For example: College Transcript-100215
    • When uploading the file, you will enter your full name, and Dropbox will append it to the file.
    • The final file becomes: Betty White – College Transcript-100215

    Please select the folder which corresponds with your LAST NAME.

    NAMES A-D

    NAMES E-K

    NAMES L-S

    NAMES T-Z

    This applicant states that s/he has received hours of supervision from you, a minimum of 5 of those hours with video (or observation) of the actual session.

    Do you attest to the truthfulness of this statement?

    Are you an endorsed EPT/S?

    If so, what number?
    Signature
    Date
    Printed Name
    EPT/S Number
    By signing this application, I attest that information, statements and documents provided in this application are true and reflect my true experience, education and training.


    Application Fee and Payment Options

    Associate - $50.00 Yearly
    Renewal Fee: $25.00*



    *In addition to at least three hours of EPT Continuing Education

    I give permission for my name, credentials, state, and email address to be published on the experiential play therapy website.
    (Signature)
    (Date)