UPIKE Play Therapy Path Application

UPIKE Play Therapy Path Application
Thank you for your interest in UPIKE’s Play Therapy Path. This application is designed to gather information about your academic background, professional experience, supervision needs, and readiness to participate in coursework and supervision aligned with play therapy training. Before applying, please ensure you meet the general eligibility requirements for the Play Therapy Path. Additional materials (e.g., transcript, reference, background check) will be requested as part of the review process.
Applicant Information
Email
example@example.com
Legal Name
Preferred Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender

Other
Race/ethnicity

Other
Current Status
Current academic status
Current academic or professional status
Educational Background
Which best describes your interest in the Institute?
What is your current educational level?
Undergraduate Institution
Undergraduate Major
Graduate Institution , if applicable
Graduate Major
If you did not attend the University of Pikeville for your undergraduate degree, please submit your transcripts here:

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if you are currently enrolled in or have completed a graduate degree, please submit your transcripts here:

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Professional Experience
If you are currently working in a clinical, please briefly describe your role and the population you serve.
Job Description if you are currently working in a clinical field

PDF, DOC, or DOCX
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Contact person / Supervisor at place of employment
Supervisor email
example@example.com
Supervisor phone number
Please enter a valid phone number.Format: (000) 000-0000.
If you are currently working, please identify your employerand employer's address.
Employer
Employer's Address
Resume

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Timeline and Supervision
Anticipated Beginning Term for Coursework
Supervision Situation
Professional Reference

Acceptable Professional References• A current or former supervisor• A professional colleague who can speak to your clinical experience• Someone with a professional relationship to you• Someone who knows your clinical skills and ethics• Someone who can provide contact information
Name
Title/Role
Organization
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to You
Attestation
By submitting this application, I confirm that the information provided is true and accurate.
Name
Date

MonthDayYear
Should be Empty:

UPIKE Play Therapy Path Application

Applicant Information

Current Status

Educational Background

Professional Experience

Timeline and Supervision

Professional Reference

Attestation