SP Submit Application

To be completed by supervisor with input from candidate. The form is to be submitted by supervisor. Must be submitted by July 15.

Part I: Identifications
Applicant Name:*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Applicant Email:*
Primary Trainer Name:*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Primary Trainer Email:*
PART II: Educational Background
APPLICANT: I have verified that the applicant holds a minimum of a bachelor’s degree and checked the applicable degree below. I have listed the academic institution and year the degree was earned on the corresponding line.
Degree Held (Check All That Apply):*
If the applicant’s degree is listed as “Other,” please verify that the applicant has completed the required basic competency foundation in the following five mental health content areas; Human Growth and Development, Theories of Personality, Abnormal Behavior (Psychopathology), Methods of Psychotherapy, Social Systems (e.g., Family Therapy, Organizational Behavior, etc.)
I have verified that the applicant has completed the required basic competencies.
PART II: PRACTICE SETTING & STATE LICENSES OR CERTIFICATIONS (If Applicable)
If you or the applicant are licensed or certified as a master’s level mental health professional on the state or national level, complete this section. Please attach a photocopy of any current license or certification if applicable.
Applicant’s Licenses and Certifications:
Licensed As License #
Dated
MM slash DD slash YYYY
Applicant Verifying License*
- I verify that my supervisee's license(s) and/or certification(s) to practice in their professional field has never been suspended or revoked due to unethical, unprofessional, or illegal conduct.
File
Max. file size: 128 MB.
Primary Trainer's Licenses and Certifications:
Licensed As License #
Dated
MM slash DD slash YYYY
Primary Trainer Verifying License*
- I verify that my license(s) and/or certification(s) to practice in my professional field has never been suspended or revoked due to unethical, unprofessional, or illegal conduct.
File
Max. file size: 128 MB.
PART III: TRAINING & SUPERVISED EXPERIENCE
The applicant must have completed a minimum of 300 total training hours, with at least 100 of those hours completed with you, the primary trainer, and must have completed a minimum of three (3) three supervision sessions with you, the primary trainer. All supervised experience must be current, directly related to the applicant’s professional setting and scope of practice, and involve the specific applications of psychodrama, sociodrama, sociometry, or group psychotherapy. In addition, all supervised experience must have occurred no more than four (4) years from the date of this application. Please note that all supervision sessions must have been a minimum of 50 minutes in length and must have provided the applicant with the opportunity to discuss specific applications of psychodrama, sociodrama, sociometry, and/or group psychotherapy.
A. TRAINING & SUPERVISED EXPERIENCE SUMMARY:
Date started Psychodrama Training (month/year)*
Date completed initial 80 hours of Psychodrama Training (month/year)*
Number of In-Person Psychodrama Training Hours to date:*
Number of Distance Learning Psychodrama Training Hours to date:*
Total number of training hours completed with Primary Trainer to date:*
Total number of Psychodrama Training hours completed to date:*
(This is the number of In-Person Training Hours + the number of Distance Learning Training Hours combined.)
Names of all additional trainers with whom the applicant has accrued Psychodrama Training hours to date:
Trainer Name Trainer Name Trainer Name Trainer Name
B. TRAINING & SUPERVISED EXPERIENCE BEST PRACTICES: The ABE recommends, as a supervisory standard, having a signed agreement between the Primary Trainer and the Supervised Practitioner (SP). A supervision agreement typically outlines key parameters such as the responsibilities of each party, the method the SP will use to identify their supervisor to clients or participants, and the procedures for supervision sessions, documentation, and communication. It is also recommended that such an agreement be tailored to the SP’s professional field, level of licensure, and the specific parameters of their supervisory and training relationship.
(see above)*
- Once the candidate is approved as an SP, we will co-create a supervision agreement based on supervisory standards appropriate to the SP’s professional field, level of licensure, and the specific parameters of their scope of practice and training.
Part IV: Application Attestment:
Primary Trainer MUST confirm the following statements: I have carefully read and reviewed this SP Application Form and all supporting documents with the candidate and attest to the accuracy of the application and supporting documents. I understand it is my responsibility as the Primary Trainer to deliver the SP Application and supporting documents directly to the Board via email. Application and supporting documents directly to the Board.
Supervisor MUST confirm the following statements:*
- Select All
- I verify that my license(s) and/or certification(s) to practice in my professional field has never been suspended or revoked due to unethical, unprofessional, or illegal conduct.
- I have verified that the applicant’s license(s) and/or certification(s) to practice in their professional field has never been suspended or revoked due to unethical, unprofessional, or illegal conduct.
- I have reviewed the Supervised Practitioner standards with this applicant.
- This applicant has completed 300 hours of training. At least 100 of those training hours have been with me as the primary trainer.
- I have verified that any distance learning hours have met ABE distance learning requirements.
- I have reviewed the ABE “Core competencies” and “Practice Recommendations” with the candidate.
- I have witnessed this applicant adequately facilitate groups using sociometric principles effectively.
- I have witnessed this applicant adequately direct a full psychodrama or sociodrama session on at least 2 occasions.
- I have engaged in at least 3 supervision sessions with this applicant concurrent to their training experiences.
- I believe this applicant can assess prudently their own capacities and skills in a professional situation and act ethically.
- I agree to notify the ABE in writing of any changes in the supervisor agreement within 30 days of any changes.
- The candidate and I have reviewed appropriate applications of psychodrama, sociometry, and group psychotherapy within their professional scope of practice.
Part V: Upload Endorsement Form
Please upload your endorsement file below. They must be in .doc, .docx, or .pdf format.
Supervisor Endorsement Form:*
Accepted file types: doc, docx, pdf, Max. file size: 128 MB.

Please attach the endorsement letter confirming your supervision of the candidate.
Submission Date:*
MM slash DD slash YYYY

Trainer Name	Trainer Name	Trainer Name	Trainer Name

SP Application Submission

Part I: Identifications

PART II: Educational Background

PART II: PRACTICE SETTING & STATE LICENSES OR CERTIFICATIONS (If Applicable)

PART III: TRAINING & SUPERVISED EXPERIENCE

A. TRAINING & SUPERVISED EXPERIENCE SUMMARY:

Part IV: Application Attestment:

Part V: Upload Endorsement Form