Diplomate EPT/D – 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)


    EPT/D Application

    • Upload a copy of your current EPT/S status
    • OR
    • All certificates of required participation for the Associate, Therapist and Supervisor statuses
    • Upload (Attach) evidence of
    • A juried presentation on some aspect of EPT at a state or national conference within the previous three years. The presentation must be made to professional trainees in the mental health field
    • OR
    • A published article on an aspect of EPT in a juried journal or professional newsletter within the previous three years.
    • OR
    • A course outline of a graduate level course in play therapy taught within the previous three years where EPT is given equal presentation time as other major theories

    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


    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

    EPT/D - $125.00 Yearly Renewal Fee: $75.00*




    *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)