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)