Fillable ACA and AMHCA Divisions and Branches ACEP Application (NBCC | National Board for Certified Counselors)

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ACA and AMHCA Divisions and Branches ACEP Application (NBCC | National Board for Certified Counselors)

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1Updated July 2020
ACA and AMHCA Divisions and
Branches ACEP Application
This application is for divisions and branches of the American Counseling Association or
American Mental Health Counselors Association that oer live CE programs to apply for
NBCC Approved Continuing Education Provider (ACEP) status. Submission of a completed
application does not guarantee approval. NBCC will not prereview applications or programs.
Incomplete applications will not be considered.
Continuing Education Provider Information:
Name of Division or Branch:
Mailing Address:
City, State, ZIP Code:
Physical Address (if dierent from above)
:
City, State, ZIP Code:
Telephone: Email Address:
Website:
ACEP Administrator Information
The applicant must designate an authorized representative to serve as ACEP administrator. Among other responsibilities, the ACEP
administrator serves as the primary contact person with NBCC concerning all ACEP program matters.
Name:
Title:
Email Address:
Telephone:
Continuing Education Program Administrator Information
The applicant must designate a qualied representative to serve as program administrator. The program administrator must hold
an advanced degree in a mental health eld from an accredited educational institution. The program administrator is responsible
for assuring that the content of all programs oering NBCC credit and the qualications of all program presenters satisfy NBCC
requirements. The program administrator may also serve as the ACEP administrator.
Name:
Title:
Email Address:
Educational Degree and Field of Study:
Application Application Fee
Live Event Program Delivery Format only
$0 **
**The $0 fee only applies to rst-time ACA/AMHCA applications. If the division or branch has
previously failed to maintain ACEP status and wishes to reinstate that ACEP status, the applicant must
submit a $250 reinstatement fee with this application.
All fees are nonrefundable and nontransferable.
REF#1: BATCH#1:
DATE: AMOUNT:
OFFICE
USE
ONLY
2Updated July 2020
Approval Requirements
ACEP status is granted by NBCC to eligible providers demonstrating compliance with all ACEP
provider and program requirements, including all applicable terms of the NBCC Continuing
Education Provider Policy. NBCC retains the sole authority to determine if a provider qualifies
for ACEP status.
If granted ACEP status, the approved provider is authorized to oer NBCC credit for qualifying programs in the approved
delivery format.
The guiding principle and operational goal of the NBCC ACEP process is to identify qualied program providers that are
able to oer qualifying programs consistent with the requirements of the NBCC provider policy.
ACEP
status is limited to
organizations and individuals that can function independently and have the resources to satisfy all policy requirements.
ACEP Status Eligibility Requirements
In order to qualify for ACEP status, an applicant must satisfy all NBCC ACEP eligibility requirements, including
the following:
(a). The applicant currently develops and presents continuing education programs that would qualify
for credit under the policy.
(b). The applicant must suciently demonstrate that the organization or individual oers and presents at
least two dierent live programs or one home study program that would qualify for NBCC credit under
the policy.
(c). The applicant must designate an authorized representative to serve as ACEP administrator. Among
other responsibilities, the ACEP administrator serves as the primary contact person for NBCC
concerning all ACEP program matters.
(d). The applicant must designate a qualied representative to serve as the program administrator. The
program administrator must hold an advanced degree in a mental health eld from an accredited
educational institution. The program administrator is responsible for assuring that the content of all
provider programs oering NBCC credit and the qualications of all program presenters satisfy the
requirements of the policy. The program administrator may also serve as the ACEP administrator.
(e). The applicant must submit a complete ACEP application, including all required information, materials,
and fees. All ACEP application materials become the property of NBCC, and fees are not refundable.
(f). The applicant must not display any statement concerning NBCC approval or status prior to written
notication of approval from NBCC.
Programs submitted must have been created, developed, advertised, planned, and implemented by the applicant.
Sessions presented by the applicant for another provider’s program or conference will not be considered. The applicant
cannot delegate any portion of the application process to another organization. Programs submitted as part of the ACEP
application cannot be from a cosponsorship relationship or a cosponsored program.
3Updated July 2020
Application Requirements
Incomplete or unsigned applications will not be reviewed. Correct payment (if applicable) must
accompany the application.
This application is for live event delivery format only:
Live Event Delivery Format: Real-time, interactive programs either delivered in person or by electronic devices that
permit the participant to interact with the presenter(s), including qualied programs delivered solely for in-service training
directly related to employment.
1. Describe how the continuing education of counselors supports the overall goals of the provider.
2. Describe the target audience (education level and profession) to whom you direct your continuing education
programs.
3. The applicant will provide all legally required disability accommodations to participants. All live programs
oered for NBCC credit will be presented in facilities compliant with all federal and state laws, including the
Americans with Disabilities Act (ADA).
Yes No
4. Describe the process by which you select presenters/authors for your continuing education programs.
5. Does the provider
maintain policies concerning program fees, refunds, and cancellation
?
Yes No
6. Does the provider maintain a published policy concerning the review and resolution of participant complaints
and disputes related to programs? Yes No
7. Describe the organization’s procedure for verifying attendance, including a sign in/sign out procedure.
□
□
□
□
□ □
4Updated July 2020
8. Describe the organization’s procedure for distributing certicates of completion.
9. Describe the record-keeping process that will be utilized to maintain all materials listed in policy section C.10
for a period of ve years following each program.
10. Describe the method by which program evaluations are obtained from participants and how those evaluation
results are used for future program planning.
11. Describe the provisions ensuring the privacy of participants’ condential information.
12. Describe the provisions made to protect client condentiality and information that may be presented or
disclosed
during a program, consistent with the NBCC Code of Ethics.
13. Has the provider been denied approval as a continuing education provider or had a program denied approval?
Yes No
If yes, by which organization(s) was the provider or program denied and why?
□ □
5Updated July 2020
For Live Event Delivery Format
The applicant must suciently demonstrate that the provider has previously created, developed, advertised,
planned and implemented at least two dierent live programs that qualify for credit under the NBCC Continuing
Education Provider Policy.
Submit the following with this application:
1.
Completed copies of Attachment A for two dierent previously oered live event programs.
2.
Brochures, agendas and other promotional materials for the programs listed on Attachment A.
3.
Evaluation summaries for the programs listed on Attachment A and a blank evaluation form.
4.
Presenter Qualication Form accurately identifying all individual and organizational program
presenters, including the qualications, with relevant academic degree and eld of study, of
each presenter.
5.
Sample certicates of completion distributed to participants for the programs listed on Attachment A.
6.
Curriculum vitae or résumé of program administrator.
Each provider oering NBCC credit is solely responsible for submitting to NBCC all required information
and documentation demonstrating that the provider and the provider’
s programs are in compliance with the
policy. Providers failing to demonstrate compliance with the policy may be sanctioned by NBCC, including the
disqualication of noncompliant programs or providers, or suspension or termination of ACEP status.
I attest that I understand the NBCC Continuing Education Provider Policy (policy) and that the
information provided in this application and the attachments is complete. If approved as an ACEP, the
provider will comply with the terms set forth in the policy.
Name of Authorized Representative:
Signature: Date:
Send application, required materials, and payment form (if applicable) to:
NBCC CE Department
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax the application, required materials, and payment form to 336-547-0017
(Attention: CE Department).
Submission of an application does not guarantee approval. Applications are reviewed in the order they
are received.
Email continuinged@nbcc.org with questions.
6Updated July 2020
Attachment A
(1)
For Live Event Delivery Format
Submit completed copies of Attachment A for two dierent previously oered live programs.
Title of Program:
Date Oered:
Presenter(s):
Submit a Presenter Qualication Form for each presenter and identify who presented what subject matter.
This program is designed for:
Number of Participants
Estimated Number of Participants Who Were
Graduate-Level Counselors
Number of Hours of Credit Oered
Program Content Description (attach additional pages if more space is needed):
Learning Objectives:
1.
2.
3.
4.
Submit the following with this form:
1. Brochures, agendas, and other promotional materials for the program listed.
2. Evaluation summaries from the program listed and a blank evaluation form.
3. Completed Presenter Qualication Form for the program listed along with a curriculum vitae or résumé for each presenter.
4. Sample certicates of completion for the program listed.
7Updated July 2020
Attachment A
(2)
For Live Event Delivery Format
Submit completed copies of Attachment A for two dierent previously oered live programs.
Title of Program:
Date Oered:
Presenter(s):
Submit a Presenter Qualication Form for each presenter and identify who presented what subject matter.
This program is designed for:
Number of Participants
Estimated Number of Participants Who Were
Graduate-Level Counselors
Number of Hours of Credit Oered
Program Content Description (attach additional pages if more space is needed):
Learning Objectives:
1.
2.
3.
4.
Submit the following with this form:
1. Brochures, agendas, and other promotional materials for the program listed.
2. Evaluation summaries from the program listed and a blank evaluation form.
3. Completed Presenter Qualication Form for the program listed along with a curriculum vitae or résumé for each presenter.
4. Sample certicates of completion for the program listed.
8Updated July 2020
Presenter Qualication Form
In order for a provider to oer NBCC continuing education credit for a program, the subject matter must be directly
related to an NBCC content area and the presenter/author must qualify as a presenter for the subject matter presented, as
required by the NBCC Continuing Education Provider Policy.
Presenter Name:
Title of Program or Session/Workshop:
NBCC content area(s) to which the subject matter of this program is directly related (policy section G):
Select the presenter category appropriate for this individual:
Category 1 Presenter Category 2 Presenter Category 3 Presenter
Education
Degree Major or Field of Study Institution Year
Master’s
Doctorate
Other
Describe relevant experience and/or training related to topic presented/authored.
Professional Licenses or Certications:
A curriculum vitae, résumé, or other documentation to verify education, experience, and training must be attached to this
form for each presenter.
□□□
9Updated July 2020
ACA and AMHCA Branches and Divisions ACEP Application
Payment Authorization
Name of Branch or Division:
Name of Authorized Representative:
Application Application Fee
Live Event Program Delivery Format only
$0 **
**The $0 fee only applies to rst-time ACA/AMHCA applications. If the division or branch has previously
failed to maintain ACEP status and wishes to reinstate that ACEP status, the applicant must submit a $250
reinstatement fee with this application.
All fees are nonrefundable and nontransferable.
I authorize NBCC to charge the card below in the amount of $
.
Email continuinged@nbcc.org with questions.
Check or money order payable to NBCC. (Write “ACEP Application” on the memo line.)
Cardholder Signature: ________________________________________________ Date: ________________________
Daytime Telephone: ___________________________________________ Evening Telephone : ____________________________
Card Number:
Expiration
Date:
Name on Card:
Verication Code Numbers (from back of card):
Card Type:
□ VISA □ MasterCard □ American Express
Check this box and email your application to continuinged@nbcc.org. We will reach out to you via email
with instructions for submitting payment.
If you wish to submit this application via email, DO NOT complete the credit card information on this page.
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Completed 20 January 2021

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