Professional Development Workshop Proposal Form

MaMHCA is proud to offer quality, clinically relevant workshops for LMHCs and those in training towards LMHC. We offer a competitive reimbursement rate of $115 per hour to our presenters.

Submission of this form does not guarantee you will be on our Professional Development calendar. We review and vet each application carefully. If your workshop is accepted, we work together to find the best date for you to present.

Note: Clinical focused sessions usually run on Saturday mornings, while Supervision focused sessions are typically offered on Sunday mornings. Thank you for your proposal. You will hear from us within 7-10 business days from submission.

Presenter Information

Please complete all information for the Primary Presenter.

Additional faculty contact information can be added. {Optional}

Primary Presenter Name *

Primary Presenter Preferred Pronouns

Mailing Address City, State, Zipcode *

Contact Phone # *

Presenter email address *

LICENSE Type and Number [ie: LMHC 1234] Note: This in NOT your email address, it is your license number *

Have you presented for MaMHCA before? *

Yes

No

Are you a: [Note: If an, LLC, Partnership or Sole Proprietor, you must upload a W9 with this application to be paid] *

LLC

Partnership

Sole Proprietor

Corporation

Upload a completed W9 form here if you are an LLC, Partnership or Sole Proprietor - [if you have earned less than $600 this year, you will not receive a 1099] Copy this link for the fillable pdf of the W9 here: https://mamhca.box.com/s/t35q2xr6o6qx9jg87hz27lwftrlrgj40 Download it, complete it and upload it here

Is primary presenter a MaMHCA member? *

Yes

No

Presenter experience related to this topic *

Presenter current resume[s] *

Presenter current head shot *

Additional Presenter Name

Presenter Preferred Pronouns

Mailing Address City, State, Zipcode

Contact Phone #

Presenter email address

License Type and Number [for example: LMHC 1234]

Is additional presenter a MaMHCA member?

Yes

No

Additional presenter experience related to this topic

Additional presenter experience presenting on this topic

Second Presenter current resume[s]

Second presenter current head shot

Workshop Proposal Details

Workshop title - 75 characters or less please *

Please indicate how long your workshop will run *

Briefly describe this workshop. This description will be posted on the Continuing Education Calendar [100 words or less, please] *

This workshop focuses on working with these populations: *

Target Audience *

Workshop Description Summary for Website [125 words or less, please] *

To describe your learning Goals/Objectives, please create statements that indicate what attendees will/should be able to do after your workshop.

You may use these terms:

list, state, describe, differentiate, discuss, calculate, compare, contrast, choose, define, demonstrate, estimate, evaluate, locate, match, name, plan, predict, rank, recommend, select, summarizem write, etc.

Please avoid using these terms: know, learn, appreciate, value, acquire, comprehend, be familiar with, recognize, understand, etc.

Workshop Educational Goal #1 *

Workshop Educational Goal #2 *

Workshop Educational Goal #3 *

Provide a brief outline of your presentation, i.e.: Format: resource materials, experiential, lecture. Include how you will address Multicultural & Social Justice Counseling Competencies *

Bibliography: list at least 3 current references *

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Workshop Tech and Support Needs

I prefer to present [check all that apply] *

Via Zoom

In-person in Foxboro

Hybrid, both Zoom and in-person

Do you have a maximum number of attendees on Zoom? (MaMHCA can host up to 500) Enter "0 "if not applicable *

Do you have a maximum number of attendees in person? (MaMHCA can host up to 25 in our Bergstrom Conference center) Enter "0" if not applicable *

If your session is scheduled as a hybrid workshop, MaMHCA will determine the maximum number of attendees able to join via Zoom

ZOOM Specific Workshop Tech and Support Needs

To be able to support you and create the best experience for you and the learners, we would like to be able to anticipate any needs you may have.

Please verify the following:

I have reliable internet connections - or a backup plan that has been tested and works *

Yes

No

I have used ZOOM before and am comfortable with the platform *

Yes - I can teach on ZOOM

No - never used it before and will need help

Will you be able to share and run your own power point slides? *

Yes

No - I will need a tech manager 's help

N/A - No PowerPoint or other on-screen materials to share

Will you want participants to be able to enter breakout rooms as teams to discuss material? *

Yes - breakout rooms are needed

No - breakout rooms are NOT needed

Can you set up and set times for breakout rooms on your own? *

Yes - I can manage the breakout rooms myself

No - I will need help managing the breakout rooms

How many participants do you want in each breakout room? *

How long do you want in each breakout room to be open? *

Will you have a break during your workshop? *

Yes

No

If yes, at what time? (approximately) *

90 minute workshop - 10 minute break at about 45 minutes

3 hour workshop - 15 break at 90 minutes

3 hour workshop - 10 minute breaks at hour 1 and hour 2

4 hour workshop - 10 minute breaks at hour 1 and hour 3, 15 minute break at hour 2

Other Other

The assigned workshop manager will monitor the chat for questions. Depending on how many participants are present, you may have a preference as to how you want questions posed to you. *

As they come up

During short Q/A breaks during presentation

Participants are welcome to interrupt with questions

Hold them until the end of the workshop

Other Other

Is there anything else we will need to know to help be prepared? *