Therapist EPT/C Section 2 – 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.

To upload documents, please put in a zipped folder prior to uploading.

Upload copies of certificates
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)