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Forms and Resources

If you have any questions for concerns about the use or submission of these forms, contact Cindy Flores the Practicum Coordinator at

Certification Procedures (PDF) (DOC)
Practicum Registration Materials (PDF) (DOC)
Practicum Attestation (PDF) (DOC)
Sample Permission Letter (PDF)
Consent to Videotape Form (PDF) (DOC)
Session Tracking Log (PDF) (DOC)

MIM Forms

MIM Analysis Form (PDF) (DOC)
MIM Analysis Example Form (PDF)

Theraplay Supervision Session Forms

Theraplay Session Supervision Form (PDF) (DOC)
Sample Supervision Session Form (PDF)
Parent Session Supervision Form (PDF) (DOC)

Self Description by Dimension Forms
(Please include the Intermediate/Final Checklist when submitting Self-Description by Dimension Form)

Foundational Evaluation (8th Session) (PDF) (DOC)
Intermediate Evaluation Form (PDF) (DOC)
Sample Intermediate Evaluation Form (PDF)
Final Evaluation (PDF) (DOC)

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