Name: _________________________________________________________________

Address: _______________________________________________________________

City: ____________________________State: ______________Zip: _______________

Telephone: __________________ E-Mail: ____________________________________

Recommended By: ______________________________________________________

Education
High School / GED: ___________________________________Year ______________

College: ____________________________________________Degree: ____________

Graduate School: ____________________________________Degree: ____________

Special Credentials / Training
What certifications and/or license do you hold? (Not required.) Please indicate below if you do.

____LPC   ___LMFT  ___LSW  ___LCDC  ___NBCC  ___ CADAC  ____ Nurse  ____ MD 

___School Counselor___ Licensed Minister ___ Ordained Minister ___Christian Counselor 

How long have you been a minister? ______________________

Approximately how many ministry counseling hours have you logged? ______________

Any support documentation you would like to send with your application, i.e., copies of certificates, licensure, resume, etc., we will place in your student file for future reference.

Financial Information
Tuition for your Certification class is $290.00 for resident study or $240.00 for distance-ed. Tuition is required with the application.  Therapon accepts Visa and MasterCard credit cards. 

~FOR CREDIT CARD USE ONLY~

Name on the card: ______________________________________

Type of card: ___Visa ___MasterCard 

CARD NUMBER: _____________________________________________________

Amount to be charged: $_____________  Expiration date: ____________

Signature of cardholder: ______________________________________