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)