Re-Certification Form

Fields marked with an * are required

DEMOGRAPHIC INFORMATION

CLINICAL DATA (Optional)

CONTINUING EDUCATION (Required)

List below activities applying toward continuing education requirements (72 clock hours over the last 6 years) as set by the academy. Activities include coursework, seminars, conferences, workshops, readings, case management activities etc. --refer to website for more detailed information on requirements.

RE-CERTIFICATION FEE

The Academy Board has agreed to a nominal fee of $65.00 for professionals seeking re-certification. Submit with the above documentation to receive a new certificate.