Certificate Program Application | Heartland Play Therapy

Applicant Information

Certificate Program Desired*

Select the certificate program at the location you would like to attend

Name*

First Last

Preferred Name

Address*

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

Email*

Enter Email Confirm Email

Phone

Employer

Do you require any accommodations for a disability?

Please describe your disability and needs here

Are you currently licensed in a mental health field?

What license(s) do you hold:

Do you currently work in the mental health field?*

Describe your current client population:

Have you had previous sand therapy training?

List

Workshop Title	Sponsor/Facilitator	Date Attended	Training Hours

When would you like to start?

Please mark the components in which you are interested in participating:

Programs & Workshops*

Partial Program Worshops

Multiple workshops to complete 96 training hours -- use the CTRL/Command key to select more than one:

Who referred you to our program?

Sign-me up for the free newsletter

Sign me up for the free newsletter to stay up-to-date with our upcoming workshops!