Application for College/University Suicide Prevention Specialist Certification

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* 1. First and Last Name

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* 2. E-mail Address

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* 3. Phone #

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* 4. Fax #

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* 5. Mailing Address

House/Unit #

Street

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* 6. Mailing Address

City

State/Province

Zip/Postal Code

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* 7. Organization Name

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* 8. Is your organization a member of the American Association of Suicidology?

Yes

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* 9. I am currently employed as a

Psychologist

Counselor

Social Worker

Case Manager

Other (please specify)

None of the above (Student)

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* 10. My highest academic degree is

Doctoral or Terminal (Ph.D; Ed.D; Ed.S; DrPH)

Master's

Bachelor's

Associate's

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* 11. My academic area of study (Major)

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* 12. Are you licensed in your professional field?

Yes

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* 13. Are you nationally certified in your professional field?

Yes

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* 14. How many years have you worked in an educational setting post highest degree?

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* 15. How are you paying the fee for this certification?

Using my own funds; I expect to get reimbursed by my school/organization

Using my own funds; I do not expect to get reimbursed

My organization is paying for this directly

Other (please specify)

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* 16. I would like CE credits (no additional fee) should I achieve certification. I would like these from the:

Yes, as a social worker, from the National Association of Social Workers

Yes, as a psychologist, from the American Psychological Association

Yes, as a counselor from the National Board for Certified Counselors

No, I am not looking for CE credits

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* 17. How did you learn of our trainings? (social media, professional organization, membership call, colleague/friend, membership email, etc)

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* 18. I understand this application and the subsequent training materials are non-transferable.

Yes

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* 19. The undersigned, being hereby warned that intentional or unintentional false statements and the like so made may jeopardize the validity of the application, declares that he/she/they is properly authorized to execute this application; and that all statements made of his/her/they own knowledge are true; and that all statements made on information and belief are believed to be true. By typing your name below, you are signing this application electronically.

Typed Name

Date

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* 20. I understand this training is non-refundable and non-transferrable.

Yes

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* 21. Are you a student?

Yes

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* 22. Upload proof of student status (current class schedule) if applicable.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File