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APPLICATION for C. E. APPROVAL for LPC and LMFT I the undersigned applicant state and affirm that the following is true and correct and I have read and understand this form and executed it in my own hand. Sponsoring Agency Print Name Date Signature Telephone Fax Email City Address State Zip I am not the sponsor or the presenter of this presentation* Please do not list me as the contact person on the website. Name of Presentation Context Key Use the corresponding letter below to document the context of the presentation A. College course B. In-service training C. Institute D. Seminar E* Workshop F* Conference G* Distance learning Context of Presentation Total number of hour s you wish to award must exclude non-presentation time breaks meals Date s of Presentation Presentation content key Use the corresponding letter below to document the content of each individual session A. B. C. D. E* F* G* H. Human growth and development Abnormal human behavior Appraisal/assessment techniques Counseling theories/methods Professional orientation/ethics Research Group dynamics/techniques Life style/career development I. J* K. L* M. N* O. P. Social and cultural foundations Personality theories Crisis intervention Marriage/family counseling Addictions counseling Rehabilitation counseling Gerontology Human sexuality Q* R* S* T. U. V. Psychopharmacology Consultation Physical emotional health Clinical supervision Children/adolescents Theoretical foundations of marital and family systems Presenter Key Use the corresponding letter below to document the presenter qualification of each individual session LPC LMFT LBP LGC LCSW LADC/CADC CRC/CDSVRP BCBA VES Psychologist Medical doctor Nurse School Teacher Counselor Administrator Attorney CLEET ACA AAMFT APA NASW NAADAC presenter Mental Health Substance Abuse Services State or Federal Agency Graduate professor from a regionally accredited university Use the spaces below to document the individual sessions of your conference including pre-conference workshops plenary breakout sessions breaks lunch presentations etc*. Sponsoring Agency Print Name Date Signature Telephone Fax Email City Address State Zip I am not the sponsor or the presenter of this presentation* Please do not list me as the contact person on the website. Name of Presentation Context Key Use the corresponding letter below to document the context of the presentation A. Name of Presentation Context Key Use the corresponding letter below to document the context of the presentation A. College course B. In-service training C. Institute D. Seminar E* Workshop F* Conference G* Distance learning Context of Presentation Total number of hour s you wish to award must exclude non-presentation time breaks meals Date s of Presentation Presentation content key Use the corresponding letter below to document the content of each individual session A. College course B. In-service training C. Institute D. Seminar E* Workshop F* Conference G* Distance learning Context of Presentation Total number of hour s you wish to award must exclude non-presentation time breaks meals Date s of Presentation Presentation content key Use the corresponding letter below to document the content of each individual session A. B. C. D. E* F* G* H. Human growth and development Abnormal human behavior Appraisal/assessment techniques Counseling theories/methods Professional orientation/ethics Research Group dynamics/techniques Life style/career development I.