Please Note On January 1, 2019 Our fee structure and application process changed. WMHCA Continued Education Application Form Application Information(Please read accompanying application guidelines before submitting an application) Applicant Name* First Last Address* Organization Name Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person* First Last Phone*Email*The most direct email for the main contact person provided. Program Title*Date/Dates of Events*Event 1Event 2Event 3 Type of Event (Mark all that apply)* Live Event Live Streaming Event Distance Learning (Electronically Delivered) Who Is The Event For? (Mark all that apply)* Licensed Mental Health Counselors Licensed Marriage and Family Therapists Licensed Clinical Social Workers Type of Application(Definitions are in the application guidelines)Lunch and Learn* Price: $25.00 Quantity: Single Event 1-8 CE's $50.00 9-30 CE's $200.00 1-8 CE's $50.00 Price: $50.00 9-30 CE's $200.00 Price: $200.00 Multiple Workshop 1-8 CE's $150.00 9-30 CE's $250.00 1-8 CE's $150.00 Price: $150.00 9-30 CE's $250.00 Price: $250.00 Series Single 1-8 CE's $150.00 9-30 CE's $250.00 1-8 CE's $150.00 Price: $150.00 9-30 CE's $250.00 Price: $250.00 Series Multiple 1-8 CE's $150.00 9-30 CE's $250.00 1-8 CE's $150.00 Price: $150.00 9-30 CE's $250.00 Price: $250.00 Distance Course (Electronically Delivered) Single $275.00 Mulitple $350.00 Single Price: $275.00 Multiple Price: $350.00 Additional Services Expedited fee (Typical Application is 4 to 6 weeks, if you need your application processed sooner then there is an additional fee.) $100.00 Consult fee (For incomplete applications or incorrect applications) $25.00 Classified Ad/Facebook Ad (Your posting of up to 100 words will be included in the Classifieds section of the WMHCA website, and posted on Facebook) $50.00 Ad in WMHCA’s Quarterly Newsletter $75.00 Expedited fee (Typical Application is 4 to 6 weeks, if you need your application processed sooner then there is an additional fee.) Price: $100.00 Consult fee (For incomplete applications or incorrect applications) Price: $25.00 Classified /Facebook Ad (Your posting of up to 100 words will be included in the Classifieds section of the WMHCA website, and posted on Facebook) Price: $50.00 Ad in WMHCA’s Quarterly Newsletter Price: $75.00 Additional Application QuestionsDescribe your background in providing and coordinating continuing education programs for counselors or other related disciplines*List other organizations who have approved the title*Description of Event (300 words or less)*Learning Objectives (Objectives listed for each module, 1 objective for each 1 hour of instruction is most appropriate)*Documents to uploadMeans of Assessment/Evaluation (Distance Learning must have a test of comprehension)* Drop files here or Brochure or Advertisement Material (Must include 2 learning objectives)* Drop files here or Presenter CV or Resume (If multiple presenters please include all CV’s or Resume’s)* Drop files here or Vita/Bio (limit 750 words) which list how the presenter is qualified to present/teach this curriculum. MUST be attached to this application.* Drop files here or Presenter’s License* Drop files here or Detailed Timed Outline*Please refer to Application Guidelines for an example. Drop files here or Course Content(Only applies to Distance Learning, Applicants must upload the entire text or audio video if applying for distance learning CE’s.) Drop files here or Total $0.00 Payment Option*Credit CardCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Please mail check to: WMHCA 11410 NE 124th St. #658 Kirkland, WA 98034 Upcoming EventsLaw & Ethics of New Technology in Clinical Settings03/01/2019Seattle Member MeetingsMember Meeting02/08/2019SeattleMember Meeting03/08/2019SeattleMember Meeting04/12/2019Seattle
