Application: Adoptive & Foster Family Therapy Certificate Program
Application for the August - December 2019
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PLEASE NOTE: You must click the Submit button at the end of this application. You will receive a copy of your application via email. If you do not receive a confirmation email, your application has not been submitted. *
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Oregon Mental Health Provider Application for August - December 2019 Cohort
You are applying to participate in a cohort from August - December 2019 that includes 6 courses/total of 8 training days. All 70 CEU hours are free of charge as this program is being sponsored by the Oregon Dept of Human Services for Oregon mental health professionals.Your application will give you priority seating for this series only. If, for some reason, you cannot make it to all six (6) of the courses within the series, we cannot guarantee priority registration in the future series. Seating is limited to 40 participants in the classroom, and 30 participants via live video streaming. We will do our best to ensure each applicant's preferred method of attendance.

Course Meeting Dates:
8:30am-4:30pm each day
August 15-16, 2019
September 12-13, 2019
October 17-18, 2019
December 5-6, 2019

SUPPLEMENTAL APPLICATION MATERIALS
In addition to the application you will also need to submit a resume and two letters of reference emailed directly to Anna Vetter Howell, Project Manager, email anna.vetter@pdx.edu. One reference must be from a clinical supervisor and should address your commitment to providing therapy for adoptive & foster children. Both letters should speak to your professional qualifications. References may be contacted for additional information.

The Priority application deadline is July 1, 2019. The program's Advisory Group will be reviewing applications and you will be notified no later than July 15, 2019 if your application has been accepted for the August - December 2019 Cohort. Applications will be accepted after this deadline as space allows.

WE ARE CURRENTLY ACCEPTING OREGON PARTICIPANTS ONLY

Please provide the following information so that we may contact you regarding your application.
All fields are required.
Last Name: *
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First Name: *
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Preferred Name (if different)
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Home mailing address: *
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Home phone number: *
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Personal Email address: (Will be used for program correspondence) *
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Employer Name: *
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Work address: *
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Work Email address: *
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Work phone number: *
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Ethnic Background (optional) Submission of this information is optional. It is used to determine the effectiveness of efforts to provide equal education opportunity. These are federally designated categories.
Do you have the bilingual proficiency to offer therapy to clients? *
If yes, what language?
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How did you hear about this program? *
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