MaMHCA/MCEAP Application for CE Providers

Complete this form to begin the application process, please note additional information for programs:

using Virtual Platforms
using both virtual & in-person platforms
with Multiple Break Outs
offered as a Series of Workshops

Please submit application information at least six weeks prior to each program.

Applications will not be reviewed unless payment and all requested information are received.
Allow 4 to 6 weeks to be notified of the program status.
Notification will be delivered to the contact person of record via email

Save & Return

Use Save & Return for completing an application. Once submitted this application cannot be reused.

A. Program Information Overview

1. Date of application: *

2. Sponsoring organization or individual *

2a. Organization website *

2b. Has your organization been approved as a continuing education provider or had program approval with other professional associations? *

Yes

No No

2c. Has your organization been denied approval as a continuing education provider or had a program denied approval by a professional association or other organization? *

Yes

No

If yes, please explain: If yes, please explain:

3. Contact Person at sponsoring organization responsible for this application & notification of Approval/Denial *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax Number *

Email Address *

4. Program Title *

5. Name of Presenter(s) (also complete Section B) *

6. Program Date(s) *

6a. Is this a request to repeat a program? *

Yes- skip to question #27

No

7. Location

7a. Live, In-Person Program location/address

7b. Virtual: link/web address

8. Program Type: Please identify the format of the program and complete the corresponding details below

8a. Single Presentation *

Yes

No

8b.Conference with multiple breakouts? *

Yes

No

8b1. Total # of breakout sessions? (You must also Fill out Question #23, including each breakout)

8c. Workshop series? *

Yes

No

8c1. Total # of workshop sessions in the series? (You must also Fill out Question #23, including each workshop in the series)

8d. Distance Learning? (You must also fill out Question #23 for each Distance Learning event.) *

Yes

No

9. Is there a charge for this activity? *

Yes -You must have a cancellation policy, refund policy and grievance procedure.

No

9a. Attestation of cancellation policy, refund policy, and grievance procedure. *

Yes

No

10. Total number of instructional hours? Please note: All CE events are considered as one Category.

10a. Total number of instructional hours *

11. Attestation: I certify that the information I have provided is accurate. I agree to comply with the ACA and AMHCA Code of Ethics regarding the offering of activities and the requirements set forth in this application *

Yes

No

11a. Attestation Electronic Signature *

11b. Attestation date: *

12. Course Description (up to 500 characters)

13. List three learning (not teaching) objectives *

10/500 characters

14. Indicate target audience for your program: (Please check as many as apply) *

LMHC

LICSW and other mental health professionals

General Public

Other, please specify Other, please specify

14a. Instructional methods utilized during program. Check all that apply. *

Lecture via workshop/seminar

Case presentation

Discussion groups

Other, please specify Other, please specify

14b. Type of distance learning program:. Check all that apply. *

Home study publication or online article

Audio (Audio tape, CD, MP3, Podcast, etc)

Live interactive Webcast/Webinar

Hybrid

DVD or Video recording

Slide-only webinar

Other, please specify Other, please specify

15. List at least three (3) books or articles of reference from the bibliography *

10/500 characters