Training and Credentialing Application Form

To apply for IN-AJSOP credentialing, fill out the application form below, and click the "Submit Application" button when finished.

Level 1 - Clinical Credential (Requires Masters Degree) - $1,150.00/January 24 - January 9, 2010 in Plainfield, IN

Level 2 - Management/Program Credential (Requires Bachelors Degree) - $350.00/March 1 - March 12, 2010 in Indianapolis, IN

Level 3 - Direct Care Certificate of Training (No Degree Required) - $150.00/March 18 - March 19, 2010 at Whites Residential in Wabash, IN

Level 4 - Foster Parent Certificate of Training (No Degree Required) - $150.00/TBD

First Name*

Last Name*

Company

Current Title/Position

Address 1*

Address 2

City*

State*

Zip*

Email*

Phone*

Undergraduate College/University*

Major*

Degree*

Year*

Graduate College/University*

Major*

Degree*

Year*

Direct Service (DS) work includes assessments, individual, group, and family therapies, case management, psych-education, etc.

Estimated DS hours in the past 5 years*

Type of DS work*

Agency*

Information that should be noted in consideration of this application:

Additional Information

* Indicates a Required Field