Utah Psychological Association

Start the application process by downloading the CE application: 

CE Application (pdf) 

The text of the application is located below for easy copying into an application.

Application for UPA Endorsement of External Continuing Education

Please allow 30 days for CE approval.  In order to meet UPA CE requirements, a UPA member psychologist must be part of the planning committee.

Sponsor

Sponsor (Name of the agency or individual): 
Contact Person: 
Contact Email:
Contact Phone: 
Address:

CE Program Information

Program Title: 
Program Date(s): 
Program Location (must be handicapped accessible):


Please note the total number of CE credits requested (all presenters):
Please describe how this overall event is directly relevant to psychologists:
 
Describe how the planning committee has ensured the confidential nature of case materials or other materials if applicable:

CE Administrator

Please provide information on the person responsible for maintain a file of this event including attendance and completion of the program

CE Administrator Name:
Contact Email:
Contact Phone:
Address:

UPA Liaison

Provide the name and information of the UPA member Psychologist who has been involved in the planning of the CE event.  This person is responsible to ensure Ethical Principles will be followed and may act as a liaison for UPA

UPA Liaison Name: 
Contact Email:
Contact Phone: 
Address: 

Please provide an outline of the topics on a separate page that covers the entire event.
Please attach a copy of marketing materials including brochures as they are available.

Documentation of Presentation/s

This section must be completed for each presenter and each presentation for which you wish UPA approval. If you are offering a complex symposium, you may choose to have each presenter complete this page.

Presentation

Title of Presentation:
Date of Presentation:
Start Time:
End Time:
Number of CE credits for which you are applying:

Presenter

Presenter’s name & degree:
Presenter’s present position/s:
Presenter’s education (include basic preparation through highest degree):
Degree Institution Major Area of Study Year Degree Awarded:
Describe the presenter’s qualifications related to the presentation:

Please disclose any relevant financial relationships, in any amount that the presenter or presenter’s spouse/partner have had in the past 12 months with a commercial interest whose products or services are to be discussed in the CE activity.

Session

Describe the session. This should represent a summary of the presenter’s material.  A statement of possible risk should also be included in this summary:
Identify the format of the presentation (lecture, workshop, etc.):
Learning Objectives:  Please list what the attendees will be able do as a result of having attended this presentation.  Requirements for learning objectives as well as examples are listed in the appendix.
Provide a program evaluation form. Requirements for learning objectives as well as examples are listed in the appendix.

Application Fee and Submission

This application was submitted by:
Date: 

Fees

$25 per credit hour, not to exceed $150

Optional Fees:

☐ Check here if you would like us to advertise your event on the UPA website.  Please include an additional $100 for this service.  We will advertise for two months prior to your event.

☐ Check here is you would like us to send a notification of your event to the UPA listserve.  Please include an additional $50 for this service.  We will send your advertisement (provided by you) to the UPA listserve 2 weeks and 1 week prior to your workshop.

Payment options:

Check

Send check by mail to:

Teresa Bruce, UPA Executive Director
5442 South 900 East, Suite 512
Salt Lake City, UT  84117
utahpsych@gmail.com

Credit Card

You may call in a credit card payment at (801) 410-0337

Submission

Email application and all applicable attachments to: utahpsych@gmail.com
If you choose to mail a hard copy, mail to:

Teresa Bruce, UPA Executive Director
5442 South 900 East, Suite 512
Salt Lake City, UT  84117

Checklist

  • Outline of entire event including ALL presentations
  • Complete Documentation of Presentation/s (page 2 of this application) for each presentations
  • Copy of evaluation forms for each presentation applying for CE credit
  • Copy of promotional materials and brochures 

CE Submission Appendix

Learning Objectives:  These are observable and measurable objectives.  Please provide  peer-reviewed citations appropriate to the learning objectives.  One citation is enough if it pertains to ALL learning objectives.  An example is listed below. 

Based on Dr. Who Knows’ book entitled “Hypnosis and Work with Chronic Pain,” 1st edition, 2009, this workshop is designed to help you:

a.  Summarize basic hypnosis theory and technique.
b. Observe demonstrations of hypnotic technique and phenomena.
c. Recognize differences between acute and chronic pain.
d. Utilize hypnosis in controlling acute pain
e. Apply post-hypnotic suggestions to chronic pain.
f. Practice hypnotic technic in dyads.

Program Evaluation:  Program evaluations should be based on learning objectives.  An example is shown below.

Based on the content of the workshop, I am able to:   

 Strongly Agree    Strongly Disagree
 1. Describe at least two theoretical approaches to hypnosis.

 5

4 3
 2. Employ at least two hypnotic induction techniques.

 5

 3. Explain how psychological approaches differ when applied to acute vs chronic pain.

 5

 4 3 21
 4. Demonstrate a technique for applying hypnosis to acute pain

 5

 4 3 21
 5. Provide a post-hypnotic suggestion for controlling chronic pain

 5

 4 3 21
 6. State that I had the opportunity to practice the technique during the workshop

 5

 4 3 2

1

UPA Address: 5442 South 900 East, Suite 512 | Salt Lake City, UT 84117 |(801) 410-0337
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