LOUISIANA COUNSELING ASSOCIATION
353 LEO
SHREVEPORT, LOUISIANA 71105
APPLICATION
FOR APPROVED PROVIDER STATUS
Please download and use this form.
Name of Sponsor (person or
agency):____________________________________
Address_____________________________City,State&ZIP_______________________
Telephone(___)___________FAX:
(___)___________EMail____________________
Program
Title:________________________________________________________
Presenter:__________________________________(Vitae or
Resume should be attached to this form)
Content of the
Program:___________________________________________________
_________________________________________________(A
brochure may be attached to this form)
Presentation Level: ___Introductory
__Intermediate ___Advanced(See informational letter for
description)
Location of
Program:___________________________________________(Be
specific)
Date of
Program:________________________________________________
Beginning Time_______Ending Time_______
Any
Inclusions (i.e.lunch, continental breakfast, materials,
etc________________
Number of CEH (Contact Education Hours)
requested:______________________
Specific breakdown of
time thatparticipants are in contact with the presenter should
be attached to this form. Contact hours will not be awarded
for meal or break periods or for business meeting periods
unless counseling educational content is presented which is
consistent with the requirements for the rest of the
program..
Contact
Person:___________________________________________
Address:__________________________City, State
&ZIP________________________
Telephone(____)______________ FAX
(____)__________________
EMail:______________________________________