1 Start 2 Complete Contact Person Information (Who is responsible for this application?) Contact Name * Agency/Institution * Email * Phone * Information about program Title/Date * Description of Program (This will be included on the advertising materials * Learning Outcomes (At least 3 for 1-4 hour program. At least 5 for a 5-7 hour program. Please review the Guidelines for writing behavioral learning objectives at the end of this application for the APA standards for writing and word choice 1. * 2. * 3. * 4. 5. 6. 7. Target Audiences (Check all that apply) * Professionals Public Students Professions to receive the CE credit (Select all that apply) * Psychologists Social Workers Professional Counsenlors Licensed Marriage and Therapy Counselors List their professional degrees and any professional affiliations (attach additional pages if needed) In addition CVs for all should be submitted with this application. Speaker 1 Speaker 2 Speaker 3 Speaker 4 Speaker 5 Speaker 6 Additional speakers Foundations of Content (Where do you draw support for your presentation material?) Information about the foundations for the content of the program (check all that apply) * Peer reviewed published work (theoretical, qualitative,quantitative research, case studies Emerging/other theories or research subjected to scientific study Ethical, professional or regulatory developments related to practice Please provided at least 3 scholarly references,in APA format, that support and/or relate to the content of your presentations Reference 1 * Reference 2 * Reference 3 * Check level of instruction * Introductory Intermediate Advanced Describe how multiculturalism and diversity will be addressed and integrated into this program * Describe limitations related to your program Examples( information is presented at an introductory level and competence would require additional training, research is limited to particular populations, the material presented is still considered "emerging knowledge") Limitations * Describe possible risks, if any, associated with any approaches presented Especially note populations or disorders for which use of approach is contraindicated. Please consider risks or potential triggers that may impact those attending the presentations Possible risks * Please describe any conflicts of interest related to the to the information you will be presenting (example commercial or financial support for your program or instructors * Checklist for this application * All sections of this application are complete-no blank sections are acceptable CVs for each presenter/educator are attached with this application Writing Guidelines for learning objectives were reviewed and incorporated APA Objectives * Files must be less than 2 MB.Allowed file types: pdf. Leave this field blank
