www.philadelphiapsychology.org info@philadelphiapsychology.org

Dear Prospective Co-Sponsor:

Thank you for considering co-sponsoring your program with the Philadelphia Society of Clinical Psychologists. The organization has been a prominent local organization in the field of psychology since its inception in 1956, and since then has been accredited by the American Psychological Association to offer Continuing Education credits to co-sponsoring organizations. Along with this letter you will see the necessary materials you will need if you decide to co-sponsor with us and your program is approved by our Continuing Education Committee.

In order to consider your program for co-sponsorship, please submit the following materials:

1. Co-Sponsorship Application and fee.

2. Outline of the program with scheduled breaks listed.

3. Program objectives -minimum 3-5 objectives for 3 hour program 4-7 objectives for 4-6 hour program

4. Paragraph Summary

5. Bio sketch of Presenters

6. Curriculum Vitae

7. Bibliographic References for the workshop content

8. Course Evaluation Form -see template attached

9. Co-Sponsorship Agreement -signed please.

10. Co-sponsorship Grievance Procedure

Items 2-4 can be submitted in the form of a program brochure (program brochure must be submitted with these items and approved prior to distributing). When we receive the above items, our CE Committee will review them and consult with the co-sponsor if necessary.

After approval, please submit: A copy of the finished brochure sent to participants, adhering to guidelines below.

After the workshop, please submit:

Sign-in sheet o Full Names, Degrees, licensed psychologist (y/n), licensed social worker (y/n), signatures and

emails of all participants. Course evaluation for each participant applying for CE credit (template attached). CE request form completed by each registrant needing CE credits- $5.00 per credit ACT 48 request form completed by each registrant needing ACT 48 credits -$5.- per credit Excel Spreadsheet of all registrants-Name, Degree, Email address, phone number

For timeliness, ease of access for registrants and tracking, all certificates will be emailed to the registrants for their electronic files and to be printed by registrants when needed. Copies of all certificates can be made available to administrators for their files and history as well.

Workshop & Brochure GuidelinesThe following are the major considerations that must be made in the development of your program in order to be approved for co-sponsorship. Co-sponsoring CE activities with The Philadelphia Society of Clinical Psychologists implies that the organization requesting the co-sponsorship will meet the same guidelines as the APA-approved sponsor. The approved sponsor has the same responsibilities for the program as if it were the only sponsor of the program. Therefore, it is very important that each of the criteria listed below is met.

1. Learning objectives must be outlined for the activity.2. The content of the program or activity must be clearly planned. 3. If the instructor is not a psychologist, there must be a psychologist involved in the planning of the

workshop.4. The program or activity must be at least one hour in duration.5. CE credits, not CEU’s are awarded to participants.6. Participants must be screened so that persons inappropriate to the topic, or who are not governed by

ethical considerations, would not be enrolled. When secure psychological assessment materials are discussed, only certified school psychologists and licensed psychologists may attend.

7. The learning to be accomplished must be post-graduate in nature and build upon a completed doctorate in psychology.

8. If APA-approved status is to be advertised, a specific statement of APA approval shall be included on the promotional material.

“This program is co-sponsored by the Philadelphia Society of Clinical Psychologists and _ (your agency) _. The Philadelphia Society of Clinical Psychologists is approved by the American Psychological Association to sponsor Continuing Education for psychologists. The Philadelphia Society of Clinical Psychologists maintains responsibility for the program and its content. This program provides ________ (#) Hours of CE credits for Psychologists.”

9. Learning must be evaluated. This evaluation may be objective or subjective. This is for the purpose of giving feedback to the instructors so that future programs can be improved and not for the purpose of grading the participants.

10. The participants’ satisfaction with the presentation must be measured.11. Instructors for the program or activity must be qualified both from the point of view of their knowledge of

the area and their ability to convey material successfully.12. The instructor’s ability to convey knowledge must be assessed.13. Documentation of credit must be awarded to participants indicating satisfactory completion of the

activity. This documentation must be awarded not for participation alone but also for the evaluation of the learning process and participant satisfaction as indicated in 8, 9, and 11 above.

14. The following information must be made available to participants before they enroll: educational objectives, participants for whom the activity is designed and skill level appropriate, schedule and format, cost, refund/cancellation policy, items covered by fee, faculty credentials, and number of CE credits offered.

15. A grievance policy must be agreed upon between PSCP and the organization wishing to co-sponsor.16. There must be adherence to the Ethical Principles of Psychologists. (can be viewed at

http://www.apa.org/ethics/code/index.aspx )

1. Co-sponsorship Application

Application for program co-sponsorship to offer continuing education for psychologists

Application fee- $125.00 Please make check payable to PSCP. Fee is non-refundable. Application will not be reviewed until payment is received.

The Provider/Sponsor must submit this application at least 60 days prior to the date the program commences. Please type and email application to Robyn Bailey at info@@PhiladelphiaPsychology.org. Any supplemental material must be emailed with application to expedite approval process. All lines must be completed. Committee evaluation takes 2-3 weeks, depending on volume. Applications are reviewed on a first come, first served basis.

1. Name of person completing this application: _________________________________________________

Phone #: Email address:

2. Name of Sponsor: _____

Mailing Address of Sponsor:

Website (if applicable):

3. Date of Program:

4. Title of Program:

5. Location: ______________________________

6. Start Time: End Time: Total CE Hours Requested (actual instruction hours):

7. Instructor Name: Degree:

License # (if any) _________________________ Field of Licensure:

8. List the Psychologist(s) involved in the planning and development of this program, noting highest earned degree and current employment setting:

9. If the presenter is not a psychologist, please provide a statement of the relevance of the workshop to doctoral level psychologists:

10. Attach a list of bibliographic references that relate to the accuracy, validity, effectiveness, and/or theoretical utility of the content of the program being taught.

11. Has the Program Sponsor been approved as a co-sponsor to offer CE credits for psychologists in the past? Yes / No

12. Has the speaker presented programs in the past that have been approved to offer CE credits? Yes / NoIf yes, this one specifically? Yes / No

13. Have you applied for, or are approved to offer any other type of credit for attendees? Yes / NoIf so, please list:

Please notify the office if any changes occur to the program that differs from the information placed on the application (i.e.-time, date, location, credit hours). Committee review may be needed to approve these changes. Report of changes after workshop could result in revocation of approval by the committee for further program offerings.

2. Outline of Program

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3. Program Objectives List

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4. A paragraph summary of the program and bio-sketch of presenter(s)

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5. Bio sketch of Presenters

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6. Curriculum Vitae

Please attach to packet sent to PSCP

7. Bibliographic References for the workshop content

Please attach to packet sent to PSCP

8. Course Evaluation Form

PROGRAM TITLE HERE Evaluation

Presented by (your name) and the Philadelphia Society of Clinical PsychologistsPlace: Location NameDate: Day of Week, Date, Year Time: Start time- End Time

To receive credit for this training, please complete this form and return to monitor before exiting the workshop.

1. PRESENTER EFFECTIVENESS CIRCLE ONE (5 = highest) Presenter’s Name, Degree

Presenter was well-prepared 1 2 3 4 5Presenter seemed knowledgeable 1 2 3 4 5Presenter answered questions effectively 1 2 3 4 5Presenter stimulated audience involvement 1 2 3 4 5

2. OBJECTIVES (Content covered the stated objectives)

a. Insert Learning Objective 1…………………………… …………………………….. 1 2 3 4 5

b. Insert Learning Objective 2 ………………... …………………………...…………... 1 2 3 4 5

c. Insert Learning Objective 3..………………………………………………………… 1 2 3 4 5

d. Insert Learning Objective 4………………………………… ……………………….. 1 2 3 4 5

e. Insert Learning Objective 5………………………………… ……………………….. 1 2 3 4 5

3. RELEVANCEa. I learned something I can use in my own practice 1 2 3 4 5 b. The content addressed the cultural issues and differences

of the individuals and families I serve (if applicable) 1 2 3 4 5c. The content was appropriate for my skill level 1 2 3 4 5

4. SUPPLEMENTAL MATERIAL

a. Audiovisual aids were legible and helpful 1 2 3 4 5b. Handouts were current and useful (if applicable) 1 2 3 4 5

5. STAFF and FACILITYa. The facility was comfortable and adequate 1 2 3 4 5b. Staff were responsive and helpful 1 2 3 4 5

6. GENERAL

a. Session met or exceeded my expectations 1 2 3 4 5b. I would recommend this presentation to others 1 2 3 4 5c. How much did you learn as a result of this CE program…………………………… 1 2 3 4 5

COMMENTS:

Name (if registered to receive CE credit):

Signature:

Email Address:__________________________________________________

601 Summit Avenue, 3rd Floor • Jenkintown, PA 19046(215) 885-2562 • info@philadelphiapsychology.org

www.PhiladelphiaPsychology.org

9. Co-sponsorship Agreement Form

Co-Sponsorship Prior Agreement Form

This Program entitled ___________________________________

taking place on __________________________ will be co-

sponsored by the Philadelphia Society of Clinical Psychologists (PSCP) and

___( name of co-sponsoring organization).

PSCP is approved by the American Psychological Association (APA) to offer continuing education for psychologists. PSCP maintains responsibility for this program and will be involved in all aspects of program planning. As an approved sponsor, PSCP will ensure that the ethical principles of psychologists are upheld in the delivery of this program.

The joint planning of this activity is not to be construed as lending or transferring approval status to the co-sponsor.

The Co-Sponsoring Organization is not permitted to act as an approval body by reviewing a program or organization and is not allowed to state that it, in turn, is approved by APA. PSCP assumes the same responsibilities and liabilities when co-sponsoring this activity as if it were the sole sponsor.

In the mutual planning and delivery of this program, the responsibilities of each organization will include:

Co-Sponsoring Organization will: Submit co-sponsorship fee and application with accurate information Organize and deliver the program stated above according to guidelines on application. Collect the program content, presenter qualifications (CV), program bibliographic

references, and program objectives prior to program for approval by PSCP Collect and submit to PSCP, sign-in sheets, Course Evaluation, and Request for CE

Credit form filled out in its entirety from each attendee requesting APA credit. Submit processing fee of $____ per request ($5 per credit hour), either from co-

sponsoring organization or requesting individual, check made payable to PSCP.

PSCP will: Review the program application, content, objectives, bibliographic references, and

presenter qualifications (CV). Issue and mail APA continuing education credit approval certificate to attendees

requesting such credit upon receipt of payment. Maintain records for APA.

___________________________________ ______________________________Administrator CoordinatorPSCP Co-Sponsoring OrganizationContinuing Education Program Continuing Education Program

Please scan and email this agreement prior to program date

10. Co-sponsorship Grievance Procedure

Co-Sponsorship Grievance Procedure

When there is a complaint relating to Continuing Education presentations the procedure is as follows:

Participant(s) may make known their complaint to a member of staff at the presentation. The Grievance is addressed at this level if possible.

If the complaint is in regards to the workshop itself, than the co-sponsoring organization hosting the presentation will resolve the complaint. If the complaint is in regards to obtaining CE credit, attendance, or the quality in regards to APA standards, then the participant may contact the PSCP Administrator at 215-885-2562.

If not resolvable once contacting the PSCP Executive Director, the complaint is brought to either the PSCP CE chair or to the PSCP CE committee.

If the complaint is not satisfactorily resolved at this level it is brought to the attention of the Executive Board of PSCP as deemed appropriate.

The participant who initiated the grievance is informed of the status of his/her complaint at all levels.

Support Materials and Templates to this Process:

a. Request CE credits Cover Page-Given to each Registrant

b. Request Act 48 Credits Cover Page-Given to each registrant

c. Sample Flyer/Promotion

d. Registration/Sign In Sheet Template

e. Act 48 Sample Template

f. APA GUIDELINES for Writing Behavioral Learning Objectives and Assessments

a. Request Continuing Education Credit

Title of Workshop:

Date: # of CE credits offered:

Organization Co-Sponsoring Workshop:

Name of Attendee:

Degree:

o Licensed Psychologist

o Licensed Social Worker

Email Address: _________________________________@______________________Important. This is the method by which your certificate will be delivered.

Mailing Address:

Daytime Phone Contact #:

There is a processing fee of $5.00 per credit. Please make check payable to PSCP if not paid directly to your organization

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b. Request Continuing Professional Education Hours For Pennsylvania Certificate Holders (Act 48)

Name: _____________________________________________________________

Professional Personnel ID (created by PDE 6/06): _________________________

Email Address to send approval letter: ________________________________________ Learning Experience or In-service: Workshop

Title: _______________________________________________________________

Date: __________________________________ Time: __________________________________

Facilitator(s)/Presenter(s):______________________________________________

Co-Sponsoring Organizations:Philadelphia Society of Clinical Psychologists and Name of Your Organization

Please list the competencies gained from this program as they relate to your areas of public instruction certification:

1.

2.

3.

**Please also complete the Evaluation form and Pre/Post Test for the program you have attended and attach it to this Request Form.**

If the sponsoring agency is the PSCP, please attach a check for $15.00 (per 3 credit hours) unless you have pre-paid.

The number of professional continuing education credits requested is .

My signature below indicates that the information provided above is correct.

Applications for credit will be uploaded to the State system within three weeks of application to PSCP. Proof of having earned the certification is receipt of a letter from us regarding credit approval from the State. This receipt is generated only after we upload your information and our course information to the State’s website.

, , Signature Degree Date

c. Sample Flyer/Promotion

The Growth Opportunity Center

and the Philadelphia Society of Clinical Psychologists are pleased to offer: TOURETTE SYNDROME: A Clinical Perspective

Tourette syndrome is a neuropsychological disorder that can significantly affect the individual and their families, yet the mental health professionals have not been educated or trained to work effectively with this population. This presentation will provide a clinical perspective of Tourette syndrome and co-morbid conditions that will increase the attendees’ knowledge of TS and their ability to identify vocal and motor tics. The presenter brings both personal and professional knowledge to foster the attendees’ understanding of this neurobiological disorder.

Date: October 30, 2014Place: Gloria Dei Church

570 Welsh RoadHuntingdon Valley, PA 19006

Time: 9:30 a.m. – 12:30 p.m.Learning Objectives:Upon Completion of this training, participants will be able to:

o Identify vocal and motor ticso Assess the presence of co-morbid conditionso Provide a brief psycho-education of TS to patients and their caregiverso Recommend treatment when indicated

Our PresenterPamela Simms, Psy.D. is a licensed psychologist who specializes in Tourette syndrome and the co-morbid conditions. She is a board member of the Pennsylvania Tourette Syndrome Association (PATSA) Board of Directors, and is a volunteer group leader of the PATSA Children Support Group. Dr. Simms has presented a workshop on the topic of Tourette syndrome at the PATSA Annual Conference and an In-Service at Holy Redeemer Health Systems. Furthermore, Dr. Simms has extensively researched Tourette syndrome for her doctoral dissertation titled The Influence of Aerobic Exercise on the Symptom Severity of Tourette Syndrome. She is in group practice at The Growth Opportunity Center located in Huntingdon Valley, PA and in private practice at her home office located in Ambler, PA.

CE CreditsThis session is co-sponsored by the Philadelphia Society of Clinical Psychologists. The Philadelphia Society of Clinical Psychologists is approved by the American Psychological Association to offer Continuing Education (CE) for psychologists. The Philadelphia Society of Clinical Psychologists maintains responsibility for the program and its content. This program provides three (3) hours of CE credits for Psychologists and Social Worker Board licensees and is approved for Act 48 Credit.

FEESFunding for this session has been provided by the Growth Opportunity Center. Participants requesting CE credits will be charged $15 ($5 for each credit). A check or money order for this amount made out to THE PHILADELPHIA SOCIETY OF CLINICAL PSYCHOLOGISTS (PSCP) will be accepted on October 30, 2009.

REGISTRATIONTo register, you can email the Growth Opportunity Center at www.gocenter.net or call 215-947-8654. Please indicate if you are requesting Continuing Education and/or Act 48 credits when you register.

d. Registration/Sign In Sheet Template

Request for Continuing Professional Education Hours/PA Certificate Holders Act 48)

Workshop Registration: Sign In

Name of CE WorkshopName of Sponsoring OrganizationDate of CE Workshop

LAST NAME

FIRST NAME Degree

PSYCHOLOGIST

Circle One

SIGN IN CE credits

ACT 48 credits

ACT 48 ID#

Email Address: Print Clearly Please

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Important Formatting Note:This template was designed to copy and paste into a “LANDSCAPE” format then stretch columns to best fit.

e. Sample of ACT 48 Pre/Post Test

Title of Workshop-Integrating Twelve Step Programs into PsychotherapyDate of Workshop- 2-19-10 Co-Sponsors of Workshop- Name of Your Organization and The Philadelphia Society of Clinical Psychologists

PRE-TEST circle correct answerQuestions True False1. To become a member of AA, one must be sponsored by a current member. True False2. Each group of AA or NA can make up its own rules and traditions True False

3. The rules and regulations of AA are developed by the General Services Office in New York. True False4. AA was founded by Bill Wilson and Dr. Bob Smith in 1935. True False

5. Much of the funding for AA and NA comes from grants from government agencies such as NIDA and NIAAA.

True False

6. A therapist should never refer a patient to a Twelve-Step group; this should be done by another AA member.

True False

7. If a patient is unable to maintain sobriety on an outpatient basis, a referral to a higher level of care should be considered.

True False

8. The 12 Steps are required for all members of a Twelve-Step Fellowship. True False9. AA evolved out of a Christian-based organization called the Oxford Group. True False10. The best predictor of success in treatment is the therapist's own recovery status. True False

Test # Correct % CorrectPre-TestPost-Test

Print Name_____________________________ Signature_______________________

POST-TEST circle correct answerQuestions True False1. To become a member of AA, one must be sponsored by a current member. True False2. Each group of AA or NA can make up its own rules and traditions True False

3. The rules and regulations of AA are developed by the General Services Office in New York. True False4. AA was founded by Bill Wilson and Dr. Bob Smith in 1935. True False

5. Much of the funding for AA and NA comes from grants from government agencies such as NIDA and NIAAA.

True False

6. A therapist should never refer a patient to a Twelve-Step group; this should be done by another AA member.

True False

7. If a patient is unable to maintain sobriety on an outpatient basis, a referral to a higher level of care should be considered.

True False

8. The 12 Steps are required for all members of a Twelve-Step Fellowship. True False9. AA evolved out of a Christian-based organization called the Oxford Group. True False10. The best predictor of success in treatment is the therapist's own recovery status. True False

Answers:

1. False2. True3. False4. True5. False

6. False7. True 8. False9. True10. False

f. APA GUIDELINES for Writing Behavioral Learning Objectives and Assessments

Learning objectives, or learning outcomes, are statements that clearly describe what the learner will know or be able to do as a result of having attended an educational program or activity.

Learning objectives must be observable and measurable.

Learning objectives should (1) focus on the learner, and (2) contain action verbs that describe measurable behaviors

Verbs to consider when writing learning objectives:

list, describe, recite, write compute, discuss, explain, predict apply, demonstrate, prepare, use analyze, design, select, utilize compile, create, plan, revise assess, compare, rate, critique

Verbs to avoid when writing learning objectives

know, understand learn, appreciate become aware of, become familiar with

Example of well-written learning objectives:

This workshop is designed to help you:1. Summarize basic hypnosis theory and technique;2. Observe demonstrations of hypnotic technique and phenomena;3. Recognize differences between acute and chronic pain;4. Utilize hypnosis in controlling acute pain;5. Apply post-hypnotic suggestions to chronic pain; and6. Practice hypnotic technique in dyads.

Objective learning assessments should be written in a manner that determines whether participants learned what you planned to teach them. The evaluation (or learning assessment) should be based on the stated learning objectives of the program.

Example of well-written learning assessment:

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 12. Employ at least two hypnotic induction techniques; 5 4 3 2 13. Explain how psychological approaches differ when applied

to acute vs. chronic pain; 5 4 3 2 14. Demonstrate a technique for applying hypnosis to acute pain; 5 4 3 2 15. Provide a post-hypnotic suggestion for controlling

chronic pain; and 5 4 3 2 16. State that I had the opportunity to practice the technique

during the workshop. 5 4 3 2 1