CEU Application | Utah Psych Assoc

Contact Person: *

Phone: *

Address: *

Program Title: *

Dates of Program: *

Location of Program: *

must be handicapped accessible

Total CE Credits: *

Please note the total number of CE credits requested (all presenters)

Amount Paid Details: *

Please provide the amount paid, date, and payment method for the CE application based on our website.

Describe how this overall event is directly relevant to psychologists’: *

Program Outline:

Please provide an outline of the topics on a separate page that covers the entire event; all programs

Flyer Attachement:

Attach a copy of your marketing materials including your brochure as they are available. (Not Required)

Confidentiality and Ethical Standards: *

Describe how confidentiality of case materials or other materials will be protected, if applicable.

Ethical Standards Pyschologist

Provide information about the psychologist who will ensure the Ethical Principles of Psychologists will be
followed.

Name: *

Phone: *

Address: *

Documentation

List the person who will be responsible to maintain on file documentation of psychologists’ attendance and completion
of the programs.

Name: *

Phone: *

Address: *

Presenters

Fill out this section for each presentation applying for CE credit.

Presenter 1

Title of Presentation: *

Start and End Time: *

Example: 1:00 - 2:00pm

Number of CE credits: *

Number applying for this program

Presenter Name: *

Highest Degree Earned: *

Position:

Area of Specialty: *

Attach the presenter's current CV:

Describe the session: *

This should represent a summary of the presenter’s material. A statement of possible risk should be included in this summary. For example, risk to attendees, risk to those applying what is learned, and risk to patients.

Learning Objectives: *

Please list what the attendees to be able to do as a result of having attended the presentation summarized above. These are observable and measurable objectives and include among other goals, learning objectives for all identified risks noted in your summary. Please provide a peer-reviewed citation appropriate to the learning objectives. One citation is enough if it pertains to ALL learning objectives.

Identify the format of the presentation: *

Lecture, Workshop, etc...

Provide a program evaluation form:

Please include specific learning assessment questions based on the learning objectives noted above.

Presenter 2

Title of Presentation: *

Start and End Time: *

Example: 1:00 - 2:00pm

Number of CE credits: *

Number applying for this program

Presenter Name:

Highest Degree Earned:

Position:

Area of Specialty:

Attach the presenter's current CV:

Describe the session: *

Learning Objectives: *

Identify the format of the presentation: *

Lecture, Workshop, etc...

Provide a program evaluation form:

Please include specific learning assessment questions based on the learning objectives noted above.

Presenter 3

Title of Presentation: *

Start and End Time: *

Example: 1:00 - 2:00pm

Number of CE credits: *

Number applying for this program

Attach the presenter's current CV:

Describe the session: *

Learning Objectives: *

Identify the format of the presentation: *

Lecture, Workshop, etc...

Provide a program evaluation form:

Please include specific learning assessment questions based on the learning objectives noted above.

Presenter Name:

Highest Degree Earned:

Position:

Area of Specialty:

Presenter 4

Title of Presentation: *

Start and End Time: *

Example: 1:00 - 2:00pm

Number of CE credits: *

Number applying for this program

Attach the presenter's current CV:

Describe the session: *

Learning Objectives: *

Identify the format of the presentation: *

Lecture, Workshop, etc...

Provide a program evaluation form:

Please include specific learning assessment questions based on the learning objectives noted above.

Presenter Name:

Highest Degree Earned:

Position:

Area of Specialty:

Presenter 5

Title of Presentation: *

Start and End Time: *

Example: 1:00 - 2:00pm

Number of CE credits: *

Number applying for this program

Attach the presenter's current CV:

Describe the session: *

Learning Objectives: *

Identify the format of the presentation: *

Lecture, Workshop, etc...

Provide a program evaluation form:

Please include specific learning assessment questions based on the learning objectives noted above.

Presenter Name:

Highest Degree Earned:

Position:

Area of Specialty:

Based on the content of the workshop, I am able to:

	5 - Strongly Agree	4 - Agree	3 - Neutral	2 - Disagree	1 - Strongly Disagree
Describe at least two theoretical approaches to hypnosis
Employ at least two hypnotic induction techniques
Explain how psychological approaches differ when applied to acute vs. chronic pain
Demonstrate a technique for applying hypnosis to acute pain
Provide a post-hypnotic suggestion for controlling chronic pain
State that I had the opportunity to practice the technique during the workshop

Submitted By: *

Email Address: *

If you have any questions please contact Kathy Barnett, Ph.D. at 801-243-2273

Please note, there is a $50.00 fee per event day with a maximum fee of $150. A check can be mailed to the address below:

Teresa Bruce, Executive Director
2040 E. Murray Holladay Rd. #112
Salt Lake City, UT 84117

Content: *

Check List:

	Done
Completed application for each presenter
Outline of entire event including ALL presentations
Mail application fee per website guideline
Professional Vita for all presenter applying for CE credit
Upload promotional materials
Upload evaluation form for each presentation applying for CE credit