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.
Date started Psychodrama Training (month/year)*
Number of Hours Completed to Date:*
Number of Hours of Training Completed with Primary Trainer:*
Names of Trainers
Trainer Name Trainer Name Trainer Name Trainer Name
Part IV: Application Attestment:
My primary trainer and I have carefully read and reviewed this SP Application Form and all supporting documents and attest to the accuracy of these documents. I understand it is my responsibility to deliver the SP 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 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.
- 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 trainer.
- I have reviewed the “Core competencies” and “Practice Recommendations” listed on the ABE website with this 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. (Please note supervision sessions must have been at least 50 minutes in length and offered the applicant the opportunity to discuss specific psychodrama, sociodrama, or sociometric applications).
- 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
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Consent
I agree to the privacy policy.

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

Part IV: Application Attestment:

Part V: Upload Endorsement Form