Shreveport, Louisiana71105 Application for Lcaco-Sponsorship Or

LOUISIANA COUNSELINGASSOCIATION353LEO

SHREVEPORT, LOUISIANA71105 APPLICATION FOR LCACO-SPONSORSHIP OR

APPLICATION FOR PRE-APPROVAL OF EVENTS FOR LPC LICENSE RENEWAL

Reason forApplication:

__Iamapplyingformyeventtobepre-approvedfortheContinuingEducationClockhoursforLouisianaLicensedProfessionalCounselorsbasedontheauthorizationLCAhasreceivedfromtheLPCBoardofExaminers.

LCA will no longer co-sponsor events so no NBCC hours may be awarded.

Information about the Organization or Individual Submitting thisRequest:

Name (Person orAgency) _ Address------

CityStatezip

TelephoneNumber------Email------

IverifythatIamanNBCCProvideringoodstanding.ACEP#_

Information Concerning theWorkshop

ProgramTitle:_Location ofProgram:

Name ofVenue:------

Address:

StreetCityStateZip

DateofProgram:_Beginningtime: _ Endingtime: _

NumberofCEH(ContactEducationHours)requested:_

Please submit the agenda for the workshop. Agendas should indicate times, content areas tobeaddressed and all breaktimes.

Please indicate which of the following content areas this workshop will address:

CounselingTheory

HumanGrowthandDevelopment

SocialandCulturalFoundations

TheHelpingRelationship*

GroupDynamics

LifestyleandCareerDevelopment

AppraisaloftheIndividual

ResearchandEvaluation

ProfessionalOrientation,CounselorProfessionalIdentityandPracticeissues

MarriageandFamily***

ChemicalDependency****

Supervision***

Abnormal

Psychopharmacology

Pleaseindicatehowthecontentofthiseventaddresstheareascheckedabove(pleasebespecific;donotrefer reviewers to anattachment):

Pleaseindicatethelearningobjectivestobeaddressedbythisevent(Pleasedonotreferreviewerstoanattachment).

Upon approval, this workshop will be advertised on the LCA web site calendar. Belowpleaseindicate a short description (20-30 words maximum) of this workshop; this descriptionwillappear on the LCAcalendar:

The web entry will list contact information for registration or additional informationconcerningtheworkshop. Whatinformationshouldbeincludedonthecalendar(thismaybeatelephone

number, email address or web site):

Information about thePresenter:

Name------

Please include degree (s) or certification (s) (example MA LPC)

A current educational vita must be submitted with this application.

ContactPerson:

Address:Telephone()_

E-mailAddress

All communication concerning this workshop will be emailed to the contact person atthisaddress.

Payment may be made by check or credit card and must accompany application. Feesvarybasedonlengthoftheworkshop. PleaseseetheCEUInformationPacketforfees.

PaymentMethod

Check or money order payable to Louisiana Counseling Associations (LCA)

Purchase Order (purchase order form must be included)

VISAMasterCardDiscovererAmericanExpress

Exp.Date

CVCCodeAmex:----

Cardholder' sName

Visa Master Card Discoverer

(print)_

Authorized

Signature_