Initial Approval Application Guide

Initial Approval Application Guide

Rev 11/15

initial approval application guide

General Instructions:

Prospective continuing education (CE) providers who seek approval with CAMFT mustcomplete and submit an Initial Approval Application (pages 3-16 of this document) to demonstrate compliance with requirements set forth in the CEPA Program Manual.

The application is arranged by focus area and directly corresponds to pages 2-6 in the CEPA Program Manual, which lists the specific requirements for each focus area. You will need to have the CEPA Program Manual and Application Guideto complete the application.

Visit the “CE Provider Resources” section at for guidance in adhering to the CEPA program standards.

IF YOU WERE PREVIOUSLY A BBS-APPROVED CE PROVIDER

The Board of Behavioral Sciences adopted a new set of Continuing Education Regulations that went into effect on July 1, 2015. That means formally approved Continuing Education Providers may need to make some revisions to their programs and program materials in order to comply with the new regulations. Therefore, the content of sample course syllabi, course evaluations, promotional materials, etc. should be carefully vetted using the CEPA Program Manual and Application Guide.

Specific Instructions:
Follow the instructions below to successfully complete the application.

  1. Select one (1) CE course to present as a sample course for evaluation. If you plan to offer both face-to-face and distance-learning courses, please select one (1) CE course for each type of course to present as a sample.The course content and sample documents for the course must demonstrate compliance with the standards in the CEPA Program Manual.
  2. Some sections require attachments which should be inserted aftereach relevant section and not at the end of the application.Sample documents are required. All sample documents should correspond to the CE activity selected as the sample course.
  3. Attaching a sample or addendum:All attachments must be clearly identified to reflect the section and question number associated with the document. If including additional documentation in response to a question, please add a clearly identified addendum. Do not staple attachments/addendums.
  4. First-time CE providers: If the provider applicant has never offered CE before, please include samples for a future CE offering. A sample of course evaluation responses is not required.

Checklist:Use the checklist below to ensure all required documents are included with the application.Incomplete applications will be returned.Please note handwritten applications will not be accepted.To be considered complete, an application must:

Have all supplemental materials attached
Section II, 4(a): Course syllabus /  / 
Section II, 4(b): Educational goals and specific learning objectives /  / 
Section III, 3: Course instructor/author’s vitae or resume /  / 
Section IV, 3(a): Course evaluation /  / 
Section IV, 3(b): Summary of course evaluation responses /  / 
Section V, 14: Post-test (Only applicable if offering distance-learning education and the format
does not provide the participant opportunities to interact with the instructor and ask questions.) / N/A / 
Section V, 17: Document used to award credit to participants /  / 
Section V, 22: Promotional material/advertisement /  / 
Have each section completed
Be signed and dated
Be accompanied by the appropriate fees
$300 application fee | $200 application fee for CAMFT Chapters/members who are individual CE providers
The non-refundable application fee is an administrative fee for review of your application. Upon approval, a $300 establishment fee
will be invoiced to the CE provider. Submit a check, money order, or credit card (VISA, MC, AMEX, and Discover) payment. Cash will
not be accepted.

Directions for Submitting an Application:
Completed applications may be submitted by hard copy or as an electronic document. Emailed applications are preferred.

  • Electronic submissions: The application must be one, single PDF file in the exact order of the blank application with samples attached after each relevant section. Any sample or addendum must be properly labeled to reflect the section and question number associated with the document. Any applications not following this format will be returned. Applications can be emailed to . Payments for electronically submitted applications can be taken over the phone at (858) 429-7536.
  • Hard copy submissions: The application must be in the exact order of the blank application with samples inserted after each relevant section. Any sample or addendum must be properly labeled to reflect the section and question number associated with the document.Any applications not following this format will be returned. Please submit application with payment to: ATTN: CEPA Program Coordinator, CAMFT, 7901 Raytheon Road, San Diego, CA 92111-1606.

An automated email confirmation will be sent within two (2) business days to confirm receipt of the application. Please note this email from CAMFT does not mean the application has been deemed complete.

Notice

  • Establishment fee: Upon approval, the CE provider will be invoiced for the $300 establishment fee. Do not send this fee with the Initial Approval Application.
  • CAMFT-approved providers and applicants: It is the CE provider’s responsibility to maintain awareness of the requirements set forth by the CEPA program. All resources, guidelines, policies and procedures, and applications necessary for a CAMFT-approved provider to maintain awareness of changes and updated can be found at

initial approval application
Provider* Name:
Name of Program Administrator:
Mailing Address:
Business Phone: / Business Fax:
Email Address: / Website(s):
Are you a member of CAMFT applying as an individual* CE provider?
Yes—member ID# ______No
Organization type:
Individual (one person) Group (2 or more people)
Professional association/society Governmental agency University/College
Licensed health facility Non-profit organization For profit organization
Other:
What led you to apply with CAMFT?
CAMFT reputation Colleague/word-of-mouth Internet search
Marketing/website information BBS Other:

*Please see definition in Lexicon of Terms of CEPA Program Manual

General Program Information
  1. Indicate the type of courses that will be offered: (Check all that apply)

Face-to-face (Examples: workshops, trainings, conferences, symposiums, etc.)
Distance learning* (Examples: interactive and non-interactive online, self-paced, teleconference, etc.)
  1. Describe the continuing education program* you will be offering.

  1. Indicate the primary groups you target as potential participants in the activities you intend to offer for CE credit:

LMFT / LCSW / LPCC / LEP
  1. Has the provider been approved as a continuing education provider by another entity?
If yes, please list the name of the entity, provider number issued and year of approval.
Enter text here. / New provider—never offered CE before.
  1. Has the provider been denied approval as a CE provider? If yes, please explain.

Enter text here.
  1. Has the provider done business under another provider name within the past three (3) calendar years? If yes, provide previous name.

Enter text here.

*Please see definition in Lexicon of Terms of CEPA Program Manual

  1. continuing education program goals

  1. Please provide the continuing education program goals* statement.

Enter text here.
  1. What involvement will the program administrator have in the development of the overall program goals statement?

Enter text here.
  1. Please describe the mechanism put in place for periodic evaluation and revision of the programs’ continuing education goals.

Enter text here.

*Please see definition in Lexicon of Terms of CEPA Program Manual

  1. course content[answer for sample course(s)]

Instructions: If you plan to offer both face-to-face and distance learning options, please provide a clear explanation for both courses for all questions in this section. Include the type of course format and the title of the course to distinguish responses.
  1. Please provide a description of the course content.

Enter text here.
  1. Which of the following is the course content based upon:(check all that apply)

Methodological knowledge base / Theoretical knowledge base
Research knowledge base / Practice knowledge base
Please provide information to support the methodological, theoretical, research, and/or practice knowledge basis for the sample course content?
Enter text here.
  1. Indicate which of the following requirements the sample course content meets. (check all that apply)

Demonstrates credibility through the involvement of the broader mental health practices, education, and science communities in studying or applying the findings, procedures, practices or theoretical concepts
Is related to ethical, legal, statutory or regulatory policies, guidelines, and standards that impact each respective practice
Explainhow the content meets the specific requirement(s).
Enter text here.
  1. SAMPLE:Please provide a sample of the following from the sample CE course:
  2. Course syllabus
  3. Course educational goals and specific learning objectives
(Note: The course syllabus should include the educational goals and learning objectives.)
  1. instructor/author qualifications

  1. Describe how you will select instructors/authors for your continuing education programs and what qualifications do you base these selections on?

Enter text here.
  1. Describe how you will verify the competence of individuals who have been selected as instructors/authors of your continuing education courses?

Enter text here.
  1. SAMPLE: Please provide a copy of the sample course instructor/author’s vitae or resume.

  1. courseevaluation

  1. Describe how you will obtain course evaluations from participants.

Enter text here.
  1. Explain how the provider will utilize these evaluations to improve the course or to plan for future courses.

Enter text here.
  1. SAMPLE: Please provide a sample of the following from the sample CE course:
  2. Course evaluation
    (Note: Please provide a blank copy. Do not submit completed evaluation forms. Verify the sample contains all the required elements as stated on p. 3 of the CEPA Program Manual.)
  3. Summary of course evaluation responses from the sample course
    (Note: If the sample course hasn’t occurred, please include a summary from a different course. A sample is not required for new CE providers who have never offered coursework before.)

  1. program management

  1. Program Planning*

  1. Describe the methodin place for decision-making and program planning?

Enter text here.
  1. Who is your program administrator? Describe this individual’s role (and qualifications) in ensuring CEPA standards and policies are upheld.

Enter text here.
  1. What procedures does the provider have in place for the smooth and orderly transition of administrative responsibilities in the event of an administrative change?

Enter text here.
  1. Have you co-sponsored, or do you plan to co-sponsor, continuing education activities?
    If yes, please identify the name of all co-sponsors for the past year.

Enter text here.
  1. Describe or attach the procedures in place to identify and document the functions of each participating party when co-sponsoring activities. Specify how your organization will maintain the responsibility for following CAMFT’s requirements for providers.

Enter text here.

*Please see definition in Lexicon of Terms of CEPA Program Manual

  1. program management

  1. Maintenance of Program Records

  1. What type of records will you obtain and maintain for CE offerings?

Enter text here.
  1. Describe how you will maintain administrative and academic records for your continuing education program for a period of four years following the date of the activity.

Enter text here.
  1. Describe the steps a course participant must follow to receive copies of past continuing education records.

Enter text here.
  1. Briefly describe measures taken to secure participant’s personal/financial information (i.e., how you protect information gathered electronically* or via hard copy?)

Enter text here.
  1. If you offer online registration for events and/or online distance learning courses, please describe the measures taken to ensure the technology utilizedis reliable.

Enter text here.

*Please see definition for Electronic Security Measures in Lexicon of Terms of CEPA Program Manual

  1. program management

  1. Awarding Course Credit* and Monitoring Attendance

  1. Explain how the provider will determine the number of credit hours awarded for the completion of CE courses? Please include a separate explanation if you plan to offer distance learning courses.

Enter text here.
  1. Describe your method for documenting an individual’s participation in a course for continuing education credit?

Enter text here.
  1. For distance learning providers only: Describe the method(s) you will use to verify the individual receiving credit participated in the activity and completed all required work.

Enter text here.
  1. SAMPLE: For distance learning providers only: Is the sample distance-learning course interactive? (i.e., the CE course’s format allowed the participant an opportunity to interact with the instructor and ask questions in real-time.)
    Yes(no sample required)
    No—sample post-test required (since the sample CE course’s format did not provide the participant opportunities to interact with the instructor and ask questions).
(Note: The document should correspond to the sample distance-learning course.)

*Please see definition in Lexicon of Terms of CEPA Program Manual

  1. program management

  1. Record of Course Completion

  1. Indicate the type of document you will give to participants upon completion of an activity and the information this document contains.

Enter text here.
  1. For distance learning courses, how will the certificate of completion be sent to the participant?

Enter text here.
  1. SAMPLE: Please provide a sample of the document used to award CE credit to participants.
    (Note: The document should correspond to the sample CE course.Verify the sample contains all the required elements as stated on p. 5 of the CEPA Program Manual.)

  1. program management

  1. Promotion and Advertising

  1. List all web addresses in which you plan to promote continuing education courses.

Enter text here.
  1. List other forms in which material may be published or advertised (e.g., mailed brochures, magazines, etc.).

Enter text here.
  1. Provide your refund/cancellation policy.

Enter text here.
  1. Describe how you will notify potential participants that arrangements can be made and accommodations are available to those with disabilities.

Enter text here.
  1. Attach one (1) sample promotional material from the sample CE course(s).(Hint: Sample provided should demonstrate compliance with all the promotional/advertising requirements per the CEPA Program Manual.)

  1. program management

  1. Grievance*

  1. Describe how you will acknowledge and respond to participant complaints or grievances in a reasonable, ethical and timely manner.

Enter text here.
  1. Describe any complaints or grievances occurring within the past year and the steps taken to resolve the issue.

Enter text here.

*Please see definition in Lexicon of Terms of CEPA Program Manual

  1. program management

  1. Ethics

  1. How will you ensure continuing education program materials/content and venue selections are accessible to participants with disabilities.

Enter text here.
  1. How will you integrate respect for individual differences and awareness of diversity in your instructor selection, content development and organizational operations?
    If you have developed a formal policy, please attach your policy statement.

Enter text here.
  1. How will you ensure continuing education courses train licensees to treat any client in an ethically and clinically sound manner based upon current accepted standards of practice?
    If you have developed a formal policy, please attach your policy statement.

Enter text here.
Acknowledgement and Agreement
I certify the information provided herein is accurate. If approved, I agree to abide by all of the policies, procedures and guidelines as set forth in CAMFT’s CEPA Program Manual. I understand failure to abide by the policies, procedures and guidelines may place my provider status at risk.
I understand acceptance of this application does not guarantee approval. I understand the application fee is non-refundable once the application is submitted.
Provider name:
Name of Program Administrator:
Signature: / Date:
Payment Information
Fee:A non-refundable application fee of $300 must accompany this application—
($200 for CAMFT Chapters/members applying as individual providers).
Check enclosed—Amount $ Make check payable to CAMFT(There is a $25 returned check fee)
Credit card—Please charge the credit card listed below in the amount of: $
DO NOT INPUT CC# IF YOU ARE EMAILING THIS FORM.
Visa Mastercard AMEX Discover
Card Number:
Expiration date: / CSC#: (Three or four digit security code)
Name on card: / Signature:
Please submit completed application by email r by mail to: CAMFT, Attn: CEPA Program Coordinator, 7901 Raytheon Road, San Diego, CA 92111-1606.
This application will not be reviewed unless accompanied by the appropriate fees.

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