APPLICATION FOR CONTINUING EDUCATION CREDIT
SPONSORING ORGANIZATION / INDIVIDUAL: ___________________________________
______________________________________________________________________________
ADDRESS_____________________________________________________________________
CITY, STATE, ZIPCODE_________________________________________________________
TELEPHONE NUMBER__________________________________________________________
FAX NUMBER__________________________________________________________________
EMAIL ADDRESS_______________________________________________________________
CONTACT PERSON: ____________________________________________________________
ADDRESS (IF DIFFERENT FROM ABOVE) _________________________________________
_______________________________________________________________________________
TITLE OF CONFERENCE OR WORKSHOP: _________________________________________
________________________________________________________________________________
DATE(S) AND TIME SCHEDULED: ________________________________________________
LOCATION / ADDRESS: __________________________________________________________
_________________________________________________________________________________
INTENDED AUDIENCE (types of professionals):________________________________________
________________________________________________________________________________
ESTIMATED # OF PARTICIPANTS EXPECTED: _________ PSYCHOLOGISTS: __________
LPA CE Application
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Educational objectives of program (correlated with program evaluation instrument), including
relevance to the field of psychology (may attach):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Course outline/summary of educational content, including detailed time schedule (may attach):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Teaching Methods__________________________________________________________________
_________________________________________________________________________________
Total number of contact hours requested (60 minutes = one contact hour of credit) ______________
Psychologist involved in planning/evaluation: ____________________________________________
Degree: __________ Specialization: ______________________ License/Certificate # __________
Address: _________________________________________________________________________
Phone: _________________________________ Email: ___________________________________
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LPA CE Application
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PLEASE SUBMIT THE FOLLOWING ITEMS WITH APPLICATION:
1) Curriculum vita or resume for each instructor
2) Program evaluation instrument
3) For individual applicants, verification of expertise of presenter in the area of the proposed
presentation (may be included in CV), and documentation of prior effective presentations in
this area (may include copies of evaluation summaries or referrals by two professionals who are
familiar with the skills/expertise of the applicant).
4) Names, addresses, and contact information of co-sponsors, if any: __________________________
_______________________________________________________________________________
5) Application fee as follows:
$50 for single workshop
$75 for a single workshop repeated on additional dates within a 12 month period or
$75 for conferences of any length in which concurrent sessions are offered.
($25 late fee for applications submitted prior to five weeks before program)
PAYMENT METHOD:
Check amount: $________________ Check # __________________
Credit Card (Circle One) VISA MASTERCARD
DISCOVER
Card Number: ____________________________________________________________________
Name on credit card ________________________________________________________________
CSV Code: _______ Expiration Date:__________ Zip Code Associated with Card _____________
Signature of cardholder: _____________________________________________________________
Please submit all above to LPA Director Cindy Bishop cindy.bishop@checkmate-strategies.com
and copy to LPA CE Chair Dr. Gail Gillespie gailgillespie13@gmail.com.
Or mail to:
Cindy Bishop – LPA Director
Louisiana Psychological Association
P.O. Box 80053
Baton Rouge, LA 70898-0053
If you have questions, contact Cindy Bishop at (225) 923-1599
The sponsoring organization verifies that this application meets the criterion for authorization
as described in the LPA Guidelines for Approving Continuing Education Program
Authorized Agent / Title: ____________________________________________________________
Date submitted to LPA:_____________________________________________________________
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LPA CE Application
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LPA Guidelines for Approving Continuing
Education Programs
APPLICANTS
Application for approval for continuing education by the L.P.A. may be made by individuals or by accredited
schools, professional organizations, social service agencies, Veterans Administration hospitals, hospitals,
mental health centers, and other organizations that meet the criteria and conditions below.
CRITERIA FOR AUTHORIZATION FOR SPONSORING ORGANIZATIONS
Applicants must have:
1. an organizational structure for continuing education with a designated and capable professional staff
who administer and coordinate an organized schedule of continuing education;
2. a means of responsibility for control over all aspects of programs to ensure that educational objectives
and standards are met;
3. a system for selection and supervision of qualified instructors;
4. a system for evaluation of the individual presentation(s) and overall programs by participants;
5. content which is clearly for use for psychologists in their practice settings; and
6. input by a licensed psychologist in the planning and evaluation of the program. The application must
include the name, degree, certification or licensure, and telephone number of the psychologist.
(Applicants may not submit CE application forms from other professional associations).
PRESENTERS
A current vita will be reviewed for each presenter to ensure that he/she is a professional with the appropriate
background, as well as proper licensing/accreditation, in the content area of the educational activity.
CRITERIA FOR AUTHORIZATION FOR INDIVIDUAL PRESENTERS
Individual applicants who are affiliated with a sponsoring organization and who are applying as the applicant
and presenter must demonstrate:
1.
2.
3.
4.
5.
expertise in the area of the proposed presentation;
experience as an effective presenter in the topic area;
a system for evaluation of programs by participants;
content which is clearly of use for psychologists in their practice settings;
input by a licensed psychologist in the planning and evaluation of the program. The application must
include the name, degree, certification, or licensure, and telephone number of the psychologist.
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LPA CE Application
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PROGRAM QUALITY
Learning objectives and format of the proposed presentation will be reviewed to ensure high-quality learning
experiences based on clearly stated learning objectives, educational format, and explicit expectations regarding
objective gains to be acquired through participant attendance of this workshop.
PROGRAM EVALUATION INSTRUMENT:
Methods of evaluation to determine the effectiveness of continuing education should be an integral part of each
program. The program evaluation instrument must include a statement of objectives for each program and/or
presenter, evaluation of satisfaction with program objectives, presenter’s quality and content, program facilities
and arrangements, and suggestions for future programs. Program objectives should be measurable and
observable (e.g., Participants will be able to….apply a specific technique, summarize a new diagnostic category,
identify the difference between, list three new ways to, etc.). The purpose of such evaluation is to ensure that
learning needs of participants have been fulfilled, and to assist in planning better programs in the future. For
assistance in writing objectives that will enhance your application’s potential for acceptance, refer to APA’s
recommendations on writing learning objectives http://www.apa.org/ed/sponsor/resources/objectives.pdf), or
request a sample application from the LPA director.
DETERMINATION OF CREDIT HOURS
The number of contact hours (60 minutes equals one contact hour) will be determined prior to the beginning of
the program and will be based on the program objectives, content, format, methods of instruction, and schedule.
Application for approved contact hours must be made by the sponsoring organization, not by individual
participants who attend the program. Contact hour credit will include only actual instruction time with the
presenter and discussions led by the presenter or staff pre-arranged by the workshop. It shall not include
informal discussions over lunch or other non-instructional activities (e.g., welcoming speeches, introductions,
awards, etc.). In the event an educational program is connected with a meal function, credit during meal time is
only approved if the program specifically denotes that the presentation will occur during that time, along with
the duration of that part of the presentation noted in the agenda.
DOCUMENTATION OF ATTENDANCE
The sponsoring organization must monitor participant attendance at LPA-approved programs through the use of
sign-in records and/or distribution of unique course codes at the end of each program. A list of program
attendees shall be maintained by the sponsoring organization for a minimum of two years.
ISSUANCE OF CERTIFICATES
Certificates will be issued by the approved organization to all participants who have successfully completed the
program. Certificates for partial attendance may not be issued.
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CRITERIA FOR PARTICIPATION
Applicant agrees to:
1. Submit application information and application fee at least FIVE WEEKS IN ADVANCE for each
program. Continuing education will not be approved after the program has ended.
2. Certify the participation of each person in the program for whom contact hour credit is to be awarded;
3. Include in the announcement workshop program/courses and on the continuing education certificate of
the following statement:“This program has been approved by the Louisiana Psychological Association
for (number) continuing education contact hours”.
FEES
A nonrefundable fee for each program application is due upon submission of the application, as follows:
$50
for a single workshop
$75
for a single workshop, repeated on additional dates within a 12 month period
$75
conferences of any length in which concurrent sessions are offered
$25
late fee (for applications received less than five weeks prior to program)
APPROVAL PROCESS
Applicant will be notified by email upon receipt of the application, and will receive notification of approval or
denial within one week of receipt. If the application is denied, justification will be provided, along with an
opportunity to resubmit once, with corrections or adjustments, at no extra cost.
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