RPT/RPT-S Consultation Packet

• Background Form • Consultation Agreement

DR.HEIKO

RPT/RPT-S Consultation Form

Date: ___________________

Name: _____________________________________________________

Address: ___________________________________________________

___________________________________________________

Home Phone: _________________Cell Phone: ____________________

Email: _____________________________________________________

Agency/Practice Address: _____________________________________

____________________________________________________________

____________________________________________________________

Date of Birth: ____________________ Age: _____________

Certification/License # and Field of Practice: ______________________

____________________________________________________________

How were you referred to this practice? (e.g., Website, personal referral, etc.)

____________________________________________________________

Reason for consulting with this practice:

______ Individual RPT/RPT-S Consultation (Circle one please)______ Group Consultation______ Agency Consultation______ Other (Please explain)

Goals for Consultation: _____________________________________________ 
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DR.HEIKO

______ RPT Consultation _____RPT-S Consultation

Dr. Roz Training & Consultation

This note serves as a consultation agreement with regard to assisting you with fulfilling partial requirements to become a Registered Play Thera-pist or Registered Play Therapist - Supervisor (APT) with the Association of Play Therapy.

It is your responsibility to review the RPT/RPT-S Application Creden-tialing Standards guide and Application Form to ensure that you will meet the criteria on your application for the RPT Credential Standards or for the RPT-S Credential Standards. Please note that this Consultation Agree-ment does not guarantee receipt of the RPT/RPT-S credential.

I am a Registered Play Therapist-Supervisor (S-2116) with the Asso-ciation for Play Therapy. Below are the specifics of our Consultation Agreement: 

1. Consultant/Consultee:


_____________________________________

(Printed Name of Consultee) 

2. Duration: ____________________________________________

DR.HEIKO

https://www.a4pt.org/page/CredentialsInfohttps://cdn.ymaws.com/www.a4pt.org/resource/resmgr/credentials/2020_credentials/rpt_standards.pdfhttps://cdn.ymaws.com/www.a4pt.org/resource/resmgr/credentials/2020_credentials/RPT-S_Standards.pdf

3. Purpose: to partially fulfill the requirements of the RPT/RPT-S criteria.

4. Action: Dr. Heiko will provide ______________________ with consulta-tion services involving (a) 500 hours of supervised play therapy specific ex-perience; and (b) 50 hours of concurrent play therapy specific supervision. Any amendments to those hours, please list here: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Renumeration to Consultant: $150 per 50 minute session, to be paid at the time of each consultation hour.

6. Signatures:

___________________________________________Rosalind L. Heiko, Ph.D., RPT-S

___________________________________________Consultee

__________________ Date

DR.HEIKO