RMPTI REGISTRATIONFOR ON-LINE SUPERVISION PROGRAM

Name
Date
Email address:

University Degrees(s) & Dates

Relevant Training & Professional Experience:

SUPERVISION ACTIVITIES:
Please indicate the primary supervision activities that you would like to organize. The credit total should equal 8. If you wish to use more than the assigned credits for each activity; enter your desired number of credits per activity. Again, the total number of credits should equal 8.

ACTIVITY		SUGGESTED CREDITS	CREDITS REQUESTED
1. Video tape segment review		2	enter credit
2. Feedback on written report		2	enter credit
3. Case notes: format and review		1	enter credit
4. Ethical Issues		2	enter credit
5. Court Preparation		3	enter credit
6. Practice Issues i.e. Parent consultation, Securing private practice referrals, Special populations		1	enter credit
7. Case conceptualization and consultation		2	enter credit
8. Play therapy strategies		1	enter credit

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