Credential Training Provider (CTP) Application

This application is for a Credential Training Provider (organization or individual) seeking approval to offer CE credits for future, live continuing education programs. Before beginning this application, the continuing education provider (the Provider) should thoroughly read the Credential Training Provider Policy (Policy) and the entire application. CCALP will not pre-review any application or program, and incomplete or unsigned applications will not be considered.

Credential Training Provider Information

The provider is the entity that takes responsibility for the program and Policy compliance. Because the provider is responsible, the program materials must clearly identify the provider by using the “Provider Name” indicated below.

Provider Name *

Street Address *

City

State

Country

Postal code

Business Phone *

Business Website *

Title *

Email *

Application Guidelines

Each continuing education program must be submitted as a separate application and must be reviewed and approved by CCALP prior to being offered for CE credit.

In order to qualify for CTP designation, a provider must meet all eligibility requirements and satisfy all application guidelines.

Application documents must be uploaded in the application form.
Programs/workshops must be inclusive about clinical supervision, not about a certification program.
Links and emails for the documents and material to complete an application are not accepted.
Hand-written documents are not accepted.
Applications must be submitted no later than 60 business days prior to the scheduled start date of the program.
Incomplete applications are not accepted.
Applications fees are non-refundable.
Maintenance fees are non-refundable.
Changes to CCALP approved programs are not permitted and must be submitted as a new Application. This includes: program title, content, CE hours, presenter, learning objectives, delivery format type, etc.

CCALP reserves the right to deny approval and will provide feedback to the provider as to the reason.

CTP Program Administrator

The Provider must designate an authorized representative to serve as the CTP Program Administrator. The CTP Program Administrator serves as the primary contact for communications and cooperates with CCALP concerning all matters related to the CTP program. If the CTP administrator changes, the Provider must notify CCALP of the change within 30 days.

CTP Program Manager First Name *

CTP Program Manager Last Name *

1. The Provider offers CE programs in a manner that is compliant with all federal, state, and local laws, including the requirements of the Americans with Disability Act (ADA). *

Yes

No

2. The Provider conducts all educational and business activities in a responsible, lawful, and ethical manner, including compliance with all applicable local, state, and federal legal requirements. *

Yes

No

3. The Provider either owns or is legally permitted to use the materials comprising its continuing education programs. *

Yes

No

4. The Provider’s operational principles are consistent with Policy requirements and applicable legal requirements. *

Yes

No

5. The Provider maintains a policy concerning the confidentiality and security of participant information. *

Yes

No

6. The Provider maintains policies concerning program fees, refunds, and cancellation. *

Yes

No

7. The Provider maintains a published policy concerning the review and resolution of participant complaints and disputes related to programs. *

Yes

No

8. The Provider has an accurate method to verify participant attendance. *

Yes

No

9. The Provider has a procedure for distributing certificates of completion within a timely manner. *

Yes

No

10. The Provider has a secure recordkeeping process that will be utilized to maintain all materials listed in Policy Section xxx for a period of 5 years following each program. *

Yes

No

11. The Provider makes a program evaluation available to participants that permits the individual to write comments and rate satisfaction and dissatisfaction with different aspects of the program. *

Yes

No

12. The Provider has a procedure for distributing a program evaluation to participants and for incorporating the feedback to improve future programs. *

Yes

No

13. Has the Provider been the subject of a continuing education approval status revocation/termination? If yes, please explain below. *

Yes

No

Please provide a brief explanation on the reason for the revocation/termination and identify the approval body that revoked/terminated the approval status. *

Program Qualifications Details

For the application, CCALP requests specific documentation pertaining to one past live program that would qualify for LPCA credit. CCALP reserves the right to request additional documentation pertaining to additional programs that would qualify for credit. This application allows the Provider to seek approval for In-Person, Interactive Webinar, or both delivery formats.

Delivery Format: Please indicate what Delivery Format you will be providing. Select all that apply. *

In Person

Webinar

Hybrid

In Person = Real-time, interactive programs delivered in person. Webinar = Delivered electronically with audiovisual materials that permit the participant to interact with the presenter(s) in real-time.Hybrid = Both, delivered In-Person and as an Interactive Webinar.

Program Title: The provider must have assumed sole responsibility for the implementation of the submitted program. *

Presenter(s) Name: Qualifying programs must be taught by presenters who meet the qualifications, as required by the CTP Provider Policy. *

Date(s) Held: Provide the most recent date this program was offered. *

Program Description: Provide a brief summary of the program and the target audience. *

For program approval, the Provider must submit the following materials from a previously held program that would qualify for LPCA credit. Submissions MUST match the Program listed above.

1. Program Outline, detailing the topics covered.

2. List of the Program Objectives.

3. Content Area (Foundations, Models/Methods, Legal/Ethical or Specialized/Advanced).

4. Continuing Education Hours & Type (Ethics, Law, Documentation, TeleMental Health, and/or Supervision).

Materials must reference codes/guidelines from ACA, AMHCA, GA Composite Board of PC, SW, MFT, and/or NBCC.

Upload supporting documents relative to the listed program. Only pdf format accepted. *

Approved Credential Training Provider (CTP) Agreement

The Provider seeking to become an CTP must satisfy all applicable CCALP Provider Policy (Policy) requirements. CCALP retains the sole authority to determine if a provider qualifies. I understand that payment and submission of the application does not indicate approval for the CTP designation.

I understand that I may have to provide documentation to support my responses in this application, if requested by CCALP.

If approved as an CTP, the provider will comply with the terms set forth in the Policy.

On behalf of the Provider (the applicant), I attest that I have read and understand CCALP's Provider Policy (Policy) and that the information provided in this application and the attachments are complete and accurate.

Authorized Signature *

Clear

Date *

Verification

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