Therapist EPT/C – 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/C Application

    • Upload a copy of your current Associate status
    • OR
    • All certificates of required participation for the Associate status
    • Upload (Attach) copies of certificates for webinars:
    • Webinar: Metaphorical Expressions of Children in Experiential Play Therapy (EPT)®
    • Webinar: 100 Things to Say to a Bop Bag in Experiential Play Therapy (EPT)®
    • Webinar: The Impact of Domestic Violence on Young Children: Working with Children in Experiential Play Therapy (EPT)®
    • Webinar: High Conflict Divorce and Children in Experiential Play Therapy (EPT)®
    • Webinar: Parent Consultation for Children in Experiential Play Therapy (EPT)®
    • Webinar: Tracking Trauma Expressions in Experiential Play Therapy (EPT)®
    • Upload (Attach) copies of certificates for participation in:
    • Observe an Intensive
    • Full participation in an Intensive Training
    • Attach a copy of proof of your RPT status.

    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/C - $75.00 Yearly Renewal Fee: $35.00*




    *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)