Continuing Education Documentation Form
Charlene Crilley, MFT  mfc23442
Provider # PCE 4313

Copy this information into an email and send to CharleneCrilley@sbcglobal.net

Your Information

First Name_______________________________  Last Name__________________________________
                              as seen on your license

Mailing Address __________________________________   City ________________  State ____ Zip ________
                              professional location

License type (MFT, LCSW) ____________________   License number ___________________________

Phone number ____________________  Number of CEUs you are requesting _____________________

Book Information:  Book Title _________________________________________________________

Author_______________________________________  Copyright date___________________ ISBN __________

Number of pages (Specific pages you are submitting if you are not using the entire book) _________________________________________________________________________________________

Magazine Information:  Magazine name _____________________________________________

Number of pages and/or specific pages if not using the entire Magazine.  ___________________________

Article Information:  Name of Article _______________________________________________ 

Where article can be found: ___________________________________  Month_________  Year__________

Video Information

Name of video _____________________________________  Where video is available_____________________

Year produced.  I must be able to locate the video.  Length of video ____________________________

Total number of pages/time relevant to your CEU  ___________________

PostTest:  Please complete the following in order to receive your CEU Certificate

A clear, concise description of the CEU content and objectives

1. Briefly and concisely describe this book/magazine/article/video. (Circle one)

2. Describe how this book directly (patient/client care i.e., theoretical frameworks for clinical practice; intervention techniques with individuals, couples, or groups) or indirectly (legal or ethical issues, consultation, recordkeeping, office management, insurance risks and benefits, managed care issues, research obligations, supervision training) relates to your practice/work.

3. What were the key points most pertinant to your practice/work

4. How would you apply this to your practice/work

5. Would you recommend this book/magazine/article/video to another therapists. Why or why not.

Look for your CEU Certificate via email within 24 hours.

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