CERTIFICATION EXAMINATION FOR EQUINE INTERACTION PROFESSIONALS (MENTAL HEALTH AND EDUCATION)

Handbook for Candidates

SPRING 2012 TESTING PERIOD
Application Deadline: April 15, 2012 First Day of Testing: Saturday, June 2, 2012 Last Day of Testing: Saturday, June 16, 2012

FALL 2012 TESTING PERIOD

Application Deadline: September 30, 2012 First Day of Testing: Saturday, November 3, 2012 Last Day of Testing: Saturday, November 17, 2012

1350 BROADWAY 17th FLOOR NEW YORK, NY 10018 (212) 356-0660 WWW.PTCNY.COM

VISION
Promote professional credibility and achieve public confidence in the transformative value of equine-human interaction.

MISSION
To offer a credentialing process for equine interaction professionals grounded in a foundation of knowledge and experience that supports safe, humane and ethical practice.

VALUES
Integrity Compassion Excellence Respect Collaboration

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The Certification Board for Equine Interaction Professionals

TABLE OF CONTENTS
PURPOSES OF CERTIFICATION .................................................................................... - 1 REASONS FOR CERTIFICATION.................................................................................... - 2 ELIGIBILITY REQUIREMENTS........................................................................................ - 2 ADMINISTRATION ....................................................................................................... - 4 ATTAINMENT OF CERTIFICATION ................................................................................ - 4 REVOCATION OF CERTIFICATION................................................................................. - 4 APPLICATION PROCEDURE .......................................................................................... - 4 COMPLETION OF APPLICATION ................................................................................... - 5 FEES ........................................................................................................................... - 5 REFUNDS ..................................................................................................................... - 5 EXAMINATION ADMINISTRATION ............................................................................... - 6 SCHEDULING YOUR EXAMINATION APPOINTMENT .................................................... - 6 SPECIAL NEEDS ........................................................................................................... - 7 CHANGING YOUR EXAMINATION APPOINTMENT....................................................... - 7 RULES FOR THE EXAMINATION................................................................................... - 7 REPORT OF RESULTS................................................................................................... - 7 REEXAMINATION......................................................................................................... - 7 CONFIDENTIALITY........................................................................................................ - 7 CONTENT OF EXAMINATION....................................................................................... - 8 SCORING PROCEDURE................................................................................................. - 8 CONTENT OUTLINES.................................................................................................... - 9 SAMPLE QUESTIONS................................................................................................. - 14 REFERENCES.............................................................................................................. - 15 -

PURPOSES OF CERTIFICATION
The Certification Board for Equine Interaction Professionals promotes the concept of voluntary certification by examination for those who incorporate equines into their mental health or education practice. Certification is just one part of a process called credentialing and focuses specifically on the individual and is one indication of current competence in the specialized field. Certification of equine interaction mental health and education professionals provides formal recognition of basic knowledge in this field.

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REASONS FOR CERTIFICATION

1. To provide documented evidence that you have been examined by an independent professional certifying organization and found to possess a certain level of basic knowledge about the specialized field of equine interaction mental health or education. To establish a level of knowledge required for certification of equine interaction mental health or education professionals. To provide encouragement for continued personal and professional growth in the field. To provide a standard of knowledge requisite for certification; thereby assisting clients, students, the public, and members of the profession in assessment of equine interaction mental health or education professionals. To provide a direction and focus for new professionals in the field seeking to increase their knowledge and skill levels. To protect the public. To increase the credibility of the field of equine interaction education and learning.

2. 3. 4.

5. 6. 7.

ELIGIBILITY REQUIREMENTS
ELIGIBILITY FOR THE MENTAL HEALTH EXAMINATION:
1. Licensure: Copy of current license to practice mental health services (counseling, social work, substance abuse counseling, pastoral counseling, psychology, etc.) in the state where you provide services. (In some states a Masters is required, in others a bachelors degree with proper training will qualify). 2. Experience and Education: a. Three (3) years of professional service or full time equivalent experience in the field of mental health services. Include all hours involved in providing services (face to face work with clients, supervision, planning, meetings, evaluation, paperwork, etc. involved in providing services). Hours required for licensure in the state where you practice could be included. b. At least 1,000 hours (can be part of the above 3 years of experience) must be in equine interaction mental health or learning (EMH/L). The 1,000 hours of EMH/L experience could be broken down in the following manner: i. At least 550 (55%) hours of the 1,000 hours listed above must be in delivery of mental health services that incorporated equines and would include all face to face work with clients, supervision, planning, meetings, evaluation, etc. involved in providing services.

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ii.

As many as 450 (45%) of the 1,000 EMH/L hours could be in seminars, coursework, workshops, academic courses, etc. Must have written documentation of at least 60 clock hours training in equine interaction mental health or education.

Submit:
1. 2. 3. 4. 5. Application Copy of current license Resume or curriculum vitae Documentation of 60 clock hours of EMH/L related education Appropriate fee

ELIGIBILITY FOR THE EDUCATION EXAMINATION:

1. Education: A current teaching certificate or a Masters degree in human services or related field or post graduate certificate in teaching, training and development (Human Resource Organization Development or teaching, adult education, management and staff development, outdoor experiential education, faith based education and expressive arts education or certificate from a nationally recognized coaching institute). Experience: a. Three (3) years of professional experience or full time equivalent in the fields of education, adult education, management and staff development, outdoor experiential education, faith based education and expressive arts education. b. At least 1,000 hours (can be part of the above three years of experience) in equine interaction learning (EFL). The 1,000 hours of EL experience could be broken down in the following manner: i. At least 550 hours of the 1,000 hours listed above must be in delivery of equine interaction learning services and would include all face to face work with students, supervision, planning, meetings, evaluation, etc. involved in providing services.

2.

ii. As many as 450 of the 1,000 EL hours listed above could be in seminars, coursework, workshops, academic courses, etc. on EMH/L Must have written documentation of at least 60 clock hours training in equine interaction mental health or education.

Submit:
1. 2. 3. 4. 5. Application Copy of teaching certificate or Masters Degree Resume or curriculum vitae Documentation of 60 clock hours of EMH/L related education Appropriate fee

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ADMINISTRATION
The Certification Program is sponsored by the Certification Board for Equine Interaction Professionals (CBEIP). The Certification Examinations for Certified Equine Interaction Professionals (CEIP) are administered by the Professional Testing Corporation (PTC), 1350 Broadway - 17th Floor, New York, New York 10018, (212) 356-0660, www.ptcny.com. Questions concerning the examinations should be referred to PTC.

ATTAINMENT OF CERTIFICATION
Eligible candidates who pass the Certification Examinations for Equine Interaction Professionals will become either a Certified Equine Interaction Professional Mental Health or a Certified Equine Interaction Professional Education and are eligible to use the registered designation CEIP-Mental Health or CEIP-Education after their names and will receive certificates from the CBEIP. A registry of all CEIPs will be maintained by the CBEIP and may be reported in its publications. Certification as a CEIP is recognized for a period of three (3) years at which time the candidate shall either meet the continuing education requirements that are in effect or retake and pass the current Certification Examination. Recertification can be awarded by earning a minimum of 60 continuing education units during the three year certification period, of which 20 must be in equine interaction mental health or education. At the time of recertification, an application must be filed, including documentation of continuing education units, and must be accompanied by a fee of $150.

REVOCATION OF CERTIFICATION
Certification will be revoked for any of the following reasons: 1. 2. 3. Falsification of an Application. Breach of existing ethical standards of professional practice. Misrepresentation of certification status.

The Appeals Committee of the CBEIP provides the appeal mechanism for challenging revocation of Board Certification. It is the responsibility of the individual to initiate this process.

APPLICATION PROCEDURE
Handbooks for Candidates and Applications for the Certification Examination for Equine Interaction Professionals Mental Health or Education may be obtained from the Professional Testing Corporation, 1350 Broadway - 17th Floor, New York, New York 10018, (212) 356-0660, www.ptcny.com. Read and follow the directions on the Application and in this Handbook for Candidates.

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COMPLETION OF APPLICATION
Complete or fill in as appropriate ALL information requested on the Application. Mark only one response unless otherwise indicated. NOTE: The name you enter on your Application must match exactly the name listed on your current government issued photo ID such as drivers license or passport. Do not use nicknames or abbreviations. CANDIDATE INFORMATION: Starting at the top of the Application, print your name, address, daytime phone number, evening phone number, e-mail address, employer, and current medical/clinical license in the appropriate row of empty boxes. ELIGIBILITY AND BACKGROUND INFORMATION: All questions must be answered. Mark only one response unless otherwise indicated. OPTIONAL INFORMATION: These questions are optional. The information requested is to assist in complying with equal opportunity guidelines and will be used only in statistical summaries. Such information will in no way affect your test results. CANDIDATE SIGNATURE: When you have completed all required information, sign and date the Application in the space provided. PAGE 3: Complete the requested information and sign at the bottom of the page. Fold the completed Application. Mail the Application with the appropriate fee (see FEES below) in time to be received by the deadline shown on the cover of this Handbook to: CERTIFICATION EXAMINATION FOR EQUINE INTERACTION PROFESSIONALS Professional Testing Corporation 1350 Broadway 17 th Floor New York, New York 10018

FEES
Please note: Fees are NOT refundable. Application Fee for the Certification Examination for Equine Facilitated Interaction Professionals: EFMHA Members ...............................................................................$300.00 Non-EFMHA Members .......................................................................$325.00 MAKE CHECK OR MONEY ORDER PAYABLE TO: CEIP CERTIFICATION EXAMINATION Visa, MasterCard, and American Express are also accepted. Please complete the Credit Card Payment section on the Application. DO NOT SEND CASH.

REFUNDS
There will be no refund of fees. Fees may be transferred once from one testing period to the next immediate testing period only. Please note below that there can be an opportunity to reschedule within the two week testing period.

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EXAMINATION ADMINISTRATION
The Certification Examination for Equine Interaction Professionals is administered during an established two-week testing period on a daily basis, Monday through Saturday, excluding holidays, at computer-based testing facilities managed by PSI. PSI has several hundred testing sites in the United States, as well as Canada. Scheduling is done on a first-come, first-serve basis. To find a testing center near you visit: www.ptcny.com/cbt/sites.htm or call PSI at (800) 211-2754. Please note: Hours and days of availability vary at different centers. You will not be able to schedule your examination appointment until you have received an Eligibility Notice from PTC. ONLINE SOFTWARE DEMONSTRATION A Testing Software Demo Test can be viewed online. Go to http://www.ptcny.com/cbt/demo.htm

This online Testing Software can give you an idea about the features of the testing software.

SCHEDULING YOUR EXAMINATION APPOINTMENT

Once your Application has been received and processed, and your eligibility verified, you will be mailed an Eligibility Notice within 6 weeks prior to the start of the testing period. The Eligibility Notice plus current, government-issued photo identification must be presented in order to gain admission to the testing center. A candidate not receiving an Eligibility Notice at least three weeks before the beginning of the testing period should contact the Professional Testing Corporation by telephone at (212) 356-0660 with their fax number. The Eligibility Notice will indicate where to call to schedule your examination appointment as well as the dates in which testing is available. Appointment times are first-come, first-serve, so schedule your appointment as soon as you receive your Eligibility Notice in order to maximize your chance of testing at your preferred location and on your preferred date.

It is the candidates responsibility to call PSI to schedule the exam appointment.

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SPECIAL NEEDS
Special testing arrangements may be made for individuals with special needs. Submit the Application, examination fee, and a completed and signed Request for Special Accommodations Form, available from www.ptcny.com or by calling PTC at (212) 356-0660. Requests for individuals with special testing needs must be received at least EIGHT weeks before the testing period begins.

CHANGING YOUR EXAMINATION APPOINTMENT

If you need to cancel your examination appointment or reschedule to a different date within the two-week testing period you must contact PSI at (800) 211-2754 no later than noon, Eastern Standard Time, of the second business day PRIOR to your scheduled appointment.

RULES FOR THE EXAMINATION

1. Electronic devices, including but not limited to, cell phones, pagers, cameras, voice recorders, palm pilots, Blackberries, Bluetooth type devices, MP3 players (IPOD, I-Touch, etc.) cannot be operative during the examination. 2. No books or reference materials may be taken into the examination room. 3. No questions concerning content of the examination may be asked during the testing period. The candidate should read carefully the directions that are provided on screen at the beginning of the examination session.

REPORT OF RESULTS
Candidates will be notified in writing by PTC within four weeks of the close of the testing period whether they have passed or failed the examination. Scores on the major areas of the examination and on the total examination will be reported. Successful candidates will also receive certificates from the Certification Board for Equine Interaction Professionals.

REEXAMINATION
The Certification Examination for Equine Interaction Professionals may be taken as often as desired upon filing of a new Application and fee. There is no limit to the number of times the examination may be repeated

CONFIDENTIALITY
1. The Certification Board for Equine Interaction Professionals will release the individual test scores ONLY to the individual candidate. 2. Any questions concerning test results should be referred to the Certification Board for Equine Interaction Professionals or the Professional Testing Corporation.

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CONTENT OF EXAMINATION
1. The Certification Examinations for Equine Interaction Professionals is a computer-based examination composed of a maximum of 150 multiple choice, objective questions with a total testing time of three (3) hours. 2. The content for the examinations is described in the Content Outlines starting on page 9. 3. The questions for the examinations are obtained from individuals with expertise in equine interaction (from mental health professionals for the mental health examination and from education professionals for the education examination). They are reviewed for construction, accuracy, and appropriateness by the Certification Board for Equine Interaction Professionals. 4. The Certification Board for Equine Interaction Professionals, with the advice and assistance of the Professional Testing Corporation, prepares the examinations. 5. The Certification Examinations for Equine Interaction Professionals will be weighted in approximately the following manner: I. Assessment, Evaluation, and Planning ..........................................43% II. Facilitator Skills.............................................................................43% III. Administration and Risk Management...........................................14%

SCORING PROCEDURE
Prior to administration of the examinations, representatives from the Certification Board for Equine Interaction Professionals and the Professional Testing Corporation meet to review all test items for accuracy. At this meeting, the passing score for the examinations are set using recognized psychometric methods. The passing score represents the number of test items determined necessary for the candidate to answer correctly to be considered as having minimal basic knowledge of the equine interaction profession. In order to protect the security and integrity of the certification examinations, neither the Certification Board for Equine Interaction Professionals nor the Professional Testing Corporation will release examination items, candidate responses, or keys to any candidate or agency.

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CONTENT OUTLINES
CONTENT OUTLINE MENTAL HEALTH

I. ASSESSMENT, EVALUATION, AND PLANNING

A. Assessment of facility 1. Compliance with standards a. NARHA b. EFMHA c. Psycho-Social Safety Guidelines (EFMHA/NARHA) d. CHA e. Pony Club f. National Association of Therapeutic Schools & Programs 2. Laws related to client confidentiality 3. Industry compliance standards 4. Therapeutic environment/barn milieu 5. Participant privacy 6. Facility practices B. Assessment of clients 1. Initial intake process a. Client appropriateness for EFP b. Contraindications and precautions c. Assessment of risk to self and others d. Functional capacity and relevant domains i. Cognitive ii. Emotional iii. Physical iv. Spiritual 2. Informed consent of clients (permission to treat) 3. Disclosure of inherent risks 4. Gathering of psychological, social, medical history 5. Documentation of client goals 6. Limits of confidentiality (mandated reporting) C. Development and writing of treatment plan 1. Match with client goals 2. Design session/activities 3. Match interactions to client 4. Consult with equine specialist 5. Level and number of support staff needed 6. Appropriateness of volunteer support D. Implementation of treatment plan 1. Supervision of equine interactions in consultation with staff 2. Adaptation of session design to immediate circumstances 3. Debrief session with client E. Post session evaluation and review 1. Relate barn skills to treatment plan 2. Discuss results with team members 3. Document session/measure progress 4. Coordinate with external service providers/referents 5. Facilitate closure with client

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II. FACILITATOR SKILLS

A. Interpersonal relationship skills 1. Basic counseling skills and theories 2. Respecting boundaries 3. Impact of session on the client 4. Recognizing therapeutic moments Equine skills 1. Equine ethology a. Equine physiology b. Equine psychology c. Equine communication and herd dynamics d. Equine/human bond 2. Interpretation of equine behavior a. Use of metaphor and analogy b. Projection between equine and human c. Mirroring d. Recognizing equine stressors 3. Equine handling a. Training i. Consistent handling ii. Other b. Physical needs i. Age appropriate activities ii. Equine histories c. Basic equine care d. Basic equine knowledge Safety protocols/risk management 1. Safe behavior of humans around equines 2. CPR/First Aid skills 3. Safety resources 4. Intervention techniques 5. Written emergency plan 6. Impact of session on equine(s) Knowledge of standards and ethics 1. Equines 2. Humans a. Professional and personal development b. Awareness of limits and skills 3. Code of Ethics - CCEFMHEP Collaboration with therapeutic team

B.

C.

D.

E.

III. ADMINISTRATION AND RISK MANAGEMENT

A. Documentation 1. Releases 2. Crisis plans 3. OSHA 4. ADA 5. Emergency management plans 6. Accreditation 7. Policies and procedures Confidentiality and privacy 1. Interns and apprentices 2. Public relations and marketing issues 3. Media plan 4. Visitor protocols 5. HIPAA

B.

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C. D.

Insurance compliance 1. General and professional liability issues 2. Equine liability laws Business and personnel management CONTENT OUTLINE EDUCATION

I. ASSESSMENT, EVALUATION, AND PLANNING

A. Assessment of facility 1. Compliance with standards a. NARHA b. EFMHA c. Psycho-Social Safety Guidelines (EFMHA/NARHA) d. CHA e. Pony Club f. National Association of Therapeutic Schools & Programs 2. Laws related to student confidentiality 3. Industry compliance standards 4. Educational environment/barn milieu 5. Student privacy 6. Facility practices Assessment of students 1. Initial intake process a. Student appropriateness for EFL b. Contraindications and precautions c. Assessment of risk to self and others d. Functional capacity and relevant domains i. Cognitive ii. Emotional iii. Physical iv. Spiritual 2. Parameters for experiential education 3. Disclosure of inherent risks 4. Gathering of IEP, medical history 5. Documentation of student goals 6. Limits of confidentiality (mandated reporting) Development and writing of student education plan & goals and objectives 1. Match with student goals 2. Design session/activities 3. Match interactions to student 4. Consult with equine specialist 5. Level and number of support staff needed 6. Appropriateness of volunteer support Implementation of education plan & goals and objectives 1. Supervision of equine interactions in consultation with staff 2. Adaptation of session design to immediate circumstances 3. Debrief session with student Post session evaluation and review 1. Relate barn skills to student education plan & goals and objectives 2. Discuss results with team members 3. Document session/measure progress

B.

C.

D.

E.

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4. 5.

Coordinate with stakeholders/referents Facilitate closure with students

II. FACILITATOR SKILLS

A. Interpersonal relationship skills 1. Basic counseling skills and theories 2. Respecting boundaries 3. Impact of session on the student 4. Recognizing educational moments Equine skills 1. Equine ethology a. Equine physiology b. Equine psychology c. Equine communication and herd dynamics d. Equine/human bond 2. Interpretation of equine behavior a. Use of metaphor and analogy b. Projection between equine and human c. Mirroring d. Recognizing equine stressors 3. Equine handling a. Training i. Consistent handling ii. Other b. Physical needs i. Age appropriate activities ii. Equine histories c. Basic equine care d. Basic equine knowledge Safety protocols/risk management 1. Safe behavior of humans around equines 2. CPR/First Aid skills 3. Safety resources 4. Intervention techniques 5. Written emergency plan 6. Impact of session on equine(s) Knowledge of standards and ethics 1. Equines 2. Humans a. Professional and personal development b. Awareness of limits and skills 3. Code of Ethics - CCEFMHEP Collaboration with education team

B.

C.

D.

E.

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III. ADMINISTRATION AND RISK MANAGEMENT

A. Documentation 1. Releases 2. Crisis plans 3. OSHA 4. ADA 5. Emergency evacuation plans 6. Accreditation 7. Policies and procedures Confidentiality and privacy 1. Interns and apprentices 2. Public relations and marketing issues 3. Media plan 4. Visitor protocols 5. Confidentiality requirements Insurance compliance 1. General and professional liability issues 2. Equine liability laws Business and personnel management

B.

C. D.

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SAMPLE QUESTIONS
In the following questions, choose the one best answer. 1. When approaching an equine for the first time, it is usually best to touch it on the 1. 2. 3. 4. face. flank. neck/shoulder. barrel/stomach.

2. When first startled, an equines natural reaction is to 1. 2. 3. 4. run. kick. faint. freeze.

3. Which of the following is the best way a new behavior can be learned? 1. 2. 3. 4. Ask for help from others Practice the new behavior Write down everything about the new behavior Practice the old behavior in order to better understand it

4. How many beats are in a walk? 1. 2. 3. 4. 2 3 4 5

CORRECT ANSWERS TO SAMPLE QUESTIONS 1. 3; 2. 1; 3. 2; 4. 3

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REFERENCES
The following references may be of some help in preparing for the examinations. The list does not attempt to include all acceptable references, nor is it suggested that the Certification Examinations for Equine Interaction Professionals are based entirely on these references. In some cases, individual experiences are the best reference. Dawson, J. (2003). (2nd Ed.). Teaching safe horsemanship: A guide to English & Western instruction. North Adams, MA: Storey. DePrekel, M. & Welsch, T. (2003). Animal-assisted therapeutic interventions (based on DSM-IV). Saint Paul, MN: Minnesota Linking Youth, Nature, and Critters, Inc. DePrekel, M. & Welsch, T. (2003). Hands-on animal-assisted therapy and education activities. Saint Paul, MN: Minnesota Linking Youth, Nature, and Critters, Inc. Fine, A. (Ed.) (2000). Handbook on animal-assisted therapy: Theoretical foundations and guidelines for practice. San Diego, CA: Academic Press. Grandin, T. & Johnson, C. (2005). Animals in translation: Using the mysteries of autism to decode animal behavior. New York: Scribner. Hassler-Scoop, J.K. with Artz, M. (2000). Equestrian instruction: An integrated approach to teaching & learning brought to you by Hilltop Farm, Inc. Huson, MT: Goals Unlimited Press. Hassler-Scoop, J.K., Kelly, K., Benedik, L., & Kolb, R. (2000). The riding experience and beyond: Personal development for riders. Huson, MT: Goals Unlimited Press. Moreau, L. & McDaniel, I. (Eds.) (1996). Equine facilitated mental health: A field guide for practice. Self-published. Boerne, TX: Legends Equestrian Therapy; & Temple, NH: Horsepower, Inc. Editors gathered articles from professionals in the field dealing with all aspects of the work from curriculum, theoretical issues, to billing for third part reimbursement etc. Savoie, J. (2003). Its not just about the ribbons. Hong Kong: Trafalgar Square Publishing.

PTC09156-R

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NOTES

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Application for Certification Examination for Equine Interaction Professionals

(Mental Health and Education)
MARKING INSTRUCTIONS: This form will be scanned by computer, so please make your marks heavy and dark, filling the circles completely. Please print uppercase letters and avoid contact with the edge of the box. See examples provided.

Page 1 / 3

Correct: Incorrect:

Candidate Information
Mr. Mrs. First Name Ms. Dr.

Middel Initial

Last Name

Suffix (Jr., Sr. , etc.)

Number and Street

Apartment Number

City

State/Province Zip/Postal Code

Daytime Phone

Evening Phone

Email Address

Examination
A. FOR WHICH EXAMINATION ARE YOU APPLYING? B. HAVE YOU TAKEN THIS EXAMINATION BEFORE? No Yes If yes, indicate month, year, and name under
which the examination was taken.

CEIP - Mental Health

CEIP- Education

C. HAVE YOU EVER BEEN CERTIFIED AS A CEIP BY CBEIP? No

Certificate Number

Yes If yes, please provide your most recent CEIP Certificate

Expiration Year / Month

Number and Expiration Date (Attach copy of certificate)

Date (month/year): Name:

Eligibility and Background Information

Darken only one choice for each question unless otherwise directed. D. CURRENT PROFESSION (darken only one response) Drug and Alcohol Counselor Mental Health Counselor Behavior Addictions Counselor Clinical Social Worker Psychiatric Nurse Psychologist Psychiatrist LMFT School Psychologist Pastoral Counselor Special Education Primary School Teacher Secondary School Teacher Coaching Vocational Teacher College Professor Other (please describe) E. ARE YOU MEMBER OF EFMHA? If yes, membership number: No Yes

F.

ARE YOU A MEMBER OF EGEA?

No No

Yes Yes

G. ARE YOU A MEMBER OF EAGALA?

H. HIGHEST ACADEMIC LEVEL ACHIEVED: Bachelor's Degree Master's Degree Doctorate

(Continue on page 2)

37090
CBEIP, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC10068

Application for Certification Examination for Equine Interaction Professionals

(Mental Health and Education)
Eligibility and Background Information
I. YEARS OF PRACTICE WITH EQUINES: 3 - 5 years 6 - 10 years More than 10 years J. HOURS PER WEEK OF PRACTICE OR TEACHING WITH EQUINES: 0 - 1 hour/week 2 - 5 hours/week 6 - 10 hours/week 11 - 15 hours/week 16 - 24 hours/week More than 24 hours/week K. PRIMARY CLIENT/STUDENT POPULATION YOU WORK WITH: Children Adolescents Adults Families L. PRIMARY CLIENT/STUDENT POPULATION TYPE: Corporate At Risk Wellness Developmentally Delayed Schools Hospitals Corrections Other P.

Page 2 / 3

M. HOURS OF COURSES/ TRAINING IN THE LAST THREE YEARS:

Total Education/Training Hours from Page 3
Enter whole numbers only

N. NUMBER OF HOURS OF EXPERIENCE:

Total Experience Hours from Page 3 Equine Related Experience Hours from Page 3
Enter whole numbers only Enter whole numbers only

O. HAVE YOU EVER CARED FOR YOUR OWN HORSE? No No Yes Yes HAVE YOU EVER RECEIVED FORMAL RIDING INSTRUCTION?

Q. DO YOU HAVE ANY RECOGNIZED RIDING INSTRUCTION CREDENTIALS? No Yes If yes, what are they? R. HAS YOUR LICENSE OR TEACHING CERTIFICATE EVER BEEN REVOKED OR RESCINDED? No Yes If yes, please attach an explanatory statement.

Optional Information
Note: Information related to race, age, and gender is optional and is requested only to assist in complying with general guidelines pertaining to equal opportunity. Such data will be used only in statistical summaries and in no way will affect your recertification.

Race African American Asian Hispanic Native American White No Response

Age Range: Under 25 25 to 29 30 to 39 40 to 49 50 to 59 60+

Gender: Male Female

Candidate Signature

(Please fill all three pages of this application before signing below)

I have read the Handbook for Candidates and understand I am responsible for knowing it's contents. I certify that the information given in this Application is in accordance with Handbook instructions and is accurate, correct, and complete.

CANDIDATE SIGNATURE:

DATE:

CREDIT CARD PAYMENT

If you want to charge your application fee on your credit card provide all of the following information.

FOR OFFICE USE ONLY Date

Name (as it appears on your card): Address (as it appears on your statement): Charge my credit card for the total fee of: $ Expiration date (month/year): Card type: Card Number: Signature:
37090
CBEIP, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC10068

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Fee: CC Check

Visa

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Application for Certification Examination for Equine Interaction Professionals

(Mental Health and Education)
Please fill these tables and sign at the bottom of the page.

Page 3 / 3

Education/Courses/Training Table: List education/training in the field of equine interaction mental health or education, the date
you took the course /training and number of hours. (Please refer to the Handbook for Candidates for minimum requirements)

Dates

Courses/Training

Hours

Total hours

Experience Table: List the experience you have obtained. Enter dates, name of facilities and number of hours worked. (Please refer to the Handbook for Candidates for minimum requirements) Dates Facilities EquineRelated Hours Total Hours

TOTAL

I certify that the information given in this Application is in accordance with Handbook instructions and is accurate, correct, and complete.

Candidate Signature: ____________________________________________________ Print name: _______________________________________________ Applying for :

Date: _________________ CEIP-MH CEIP-ED

PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC10042