SP Submit Re-attestation

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PART I: IDENTIFICATIONS

Applicant Name:*

First Last

Applicant Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant Phone:*

Applicant Email:*

Date initially certified as Supervised Practitioner (SP):*

Are you concurrently submitting a CP Application this year?*

Yes

Primary Trainer Name:*

First Last

Primary Trainer Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Trainer Phone:*

Primary Trainer Email:*

PART II: EDUCATION

SUPERVISED PRACTITIONER EDUCATIONAL UPDATE: I have verified and, if applicable, updated the candidate’s educational information since the last SP renewal.*

No changes in academic degrees since the last SP renewal.

A new degree has been obtained since the last SP renewal. If checked, please indicate the degree, academic institution, and the date the degree was earned below:

Helpful Tip: Master’s degree is a requirement for CP application.

Degree Held (Check All That Apply):

List Degree(s) Held:*

PART III: PRACTICE SETTING(S) & STATE LICENSE(S) OR CERTIFICATION(S)

Please complete this section with all current and up-to-date information. If applicable, attach a photocopy of any license(s) or certification(s) that have been obtained since the last SP renewal. Please describe the current professional setting and scope of practice of the Supervised Practitioner as it relates to the specific applications of psychodrama, sociodrama, sociometry, or group psychotherapy discussed in supervision sessions.

Supervised Practitioner:

Current professional setting(s) and scope of practice:*

Licensed and/or Certified as (If Applicable)

License and/or Certification # and date Issued (If Applicable)

License and/or Certification issued by (If Applicable)

PRIMARY TRAINER:

Current professional setting(s) and scope of practice:*

Licensed and/or Certified as (If Applicable)

License and/or Certification # and date Issued (If Applicable)

License and/or Certification issued by (If Applicable)

PART IV: TRAINING HOURS, CONTINUING EDUCATION & SUPERVISION REQUIREMENTS

The Supervised Practitioner (SP) must complete a minimum of 20 training hours, 7 supervision sessions, and 10 continuing education hours annually to remain certified.

A. TRAINING HOURS SUMMARY:

SP’s must have at least 20 hours of psychodrama training with their primary trainer annually. Helpful Tip: If the SP is pursuing CP level certification please remain aware of the training hour requirements, including the maximum number of distance-learning hours permitted.

Number of In-Person Psychodrama Training Hours with Primary Trainer this year.*

Number of Distance Learning Psychodrama Training Hours with Primary Trainer this year.*

Number of In-Person Psychodrama Training Hours with other TEPs and/or PATs this year.*

Number of Distance Learning Psychodrama training hours With other TEPs and/or PATs this year.*

Total number of combined training hours completed this year.*

Total number of combined training hours completed since SP was initially certified.*

B. SUPERVISION SUMMARY:

Supervised Practitioners (SPs) must complete a minimum of seven individual or group supervision sessions with their primary trainer annually. Supervision sessions provided by TEPs other than the Primary Trainer, PATs, or Non-TEPs must be approved in advance by the Primary Trainer. All supervision sessions must be at least 60 minutes in length, and group supervision may not exceed four SPs per group. Helpful Tip: If the SP is pursuing CP level certification, please review the Supervised Practicum requirements on the ABE website to ensure the SP is on track to meet all additional CP requirements, including the required 40 supervision sessions.

Number of Supervision Sessions with Primary Trainer this year.*

Number of Supervision Sessions with other TEP’s or PATs this year.*

Total number of Supervision Sessions this year.*

Total number of Supervision Sessions completed since SP was certified.*

C. CONTINUING EDUCATION SUMMARY:

Supervised Practitioners (SPs) must complete a minimum of ten (10) Continuing Education (CE) hours annually in areas relevant to their scope of practice. Of these ten hours, 1 CE hour must be related to Trauma, 1 CE hour must be related to the SP’s practice setting, 1 CE hour must be related to Ethics, and 1 CE hour must be related to Culture, Identity, or Anti-Oppressive practice. The remaining 6 CE hours may be in topics relevant to the SP’s professional field, scope of practice, and interests. CE hours should be approved by one of the accrediting organizations listed on the ABE website. https://psychodramacertification.org/wp-content/uploads/2024/06/SP-Certification-Reference.pdf

D. SUPERVISED EXPERIENCE AGREEMENT UPDATES

The ABE recommends, as a supervisory standard, maintaining a current, signed supervision agreement between the Primary Trainer and the Supervised Practitioner (SP). This agreement should continue to outline key parameters such as the responsibilities of each party, the method the SP uses to identify their supervisor to clients or participants, and the procedures for supervision sessions, documentation, and communication. It is recommended that this agreement be reviewed and updated annually to ensure it remains aligned with the SP’s professional field, level of licensure, and the specific parameters of their supervisory and training relationship.

PART V: APPLICATION RENEWAL ATTESTMENT

I attest that the Supervised Practitioner (SP) and I have carefully read and reviewed this Supervised Practitioner Renewal Form and all supporting documentation. We affirm that the information provided is accurate and complete, and that we remain committed to our ongoing training and supervisory agreement. I further understand that it is my responsibility as the Primary Trainer to submit the SP Renewal Form and all supporting documentation directly to the Board via email. As the Primary Trainer I confirm the following statements:*

Please upload your files below. They must be in .doc, .docx, or .pdf format.

Primary Trainer Name, Date & Signature

Max. file size: 128 MB.

Submission Date:*