CEIP-MH Application

Hidden

Next Steps: Install the User Registration Add-On

This form requires the Gravity Forms User Registration Add-On. Important: Delete this tip before you publish the form.

Candidate Information

MM slash DD slash YYYY
Name
Address
Have you taken this Certification before?(Required)
month / year
Name exam was taken under:
if different than name listed above
Have you ever been Certified by CBEIP before?(Required)

Eligibility & Background Information

What is your current profession?(Required)
List your professional memberships:
Please click the + sign to add more lines
Highest academic level achieved:(Required)
Years of practice with equines:(Required)
Hours per week of therapy practice incorporating equines:(Required)
Primary client population:(Required)
Primary client challenges:
(Total Education/Training hours from worksheet)
(Total of Professional Experience Hours from worksheet)
(Total Education/Training hours from worksheet)

Horse Experience / Information

Do you own your own horse(s)?(Required)
Do you or have you ever cared for your own horse(s)(Required)
Have you ever received formal riding or groundwork instruction?(Required)
Do you have any recognized credentials in equine behavior, care and management, or riding?(Required)
Has your license or other professional credentials ever been revoked or rescinded?(Required)
Max. file size: 256 MB.

Disclaimer and Candidate Signature

MM slash DD slash YYYY

Next Steps

If you would like to receive a PDF / printable version of this application, please download here, and email to info@cbeip.org. Note that an incomplete application packet may cause a delay in your certification. Complete application information must be received by the submission dates of March 30, June 30 and September 30. Certification fee of $325.00 is paid directly through this form, or if submitting via email, you may visit this page to pay the fee separately.
Price: $325.00

CEIP Training & Professional Experience Hours

DIRECT FACILITATION IN EQUINE INTERACTIVE WORK
Minimum 40 Hours - attach proof of training. Please click the + to add more rows
Date
Training / Course
Presenter / Organizer
Hours
 
Drop files here or
Max. file size: 256 MB.
    ATTENDANCE AT EQUINE INTERACTION CONFERENCE, WORKSHOP OR METHOD TRAINING
    Minimum 40 Hours - attach proof of attendance. Please click the + to add more rows
    Date
    Training / Course
    Presenter / Organizer
    Hours
     
    Drop files here or
    Max. file size: 256 MB.
      FORMAL TRAINING IN EQUINE BEHAVIOR / HORSEMANSHIP
      Minimum 40 Hours - attach proof of training. Please click the + to add more rows
      Date
      Training / Course
      Presenter / Organizer
      Hours
       
      Drop files here or
      Max. file size: 256 MB.
        PROFESSIONAL EXPERIENCE
        Minimum 3 years of professional service - full time equivalent experience. Please click the + to add more rows
        Date
        Training / Course
        Presenter / Organizer
        Hours
         
        DELIVERY OF EQUINE INTERACTIVE CLIENT SERVICES
        Minimum 300 hours. Please click the + to add more rows
        Date
        Training / Course
        Presenter / Organizer
        Hours
         
        I certify that the information given in this application is in accordance with CBEIP Handbook instructions and is accurate, correct, and complete.
        MM slash DD slash YYYY
        American Express
        MasterCard
        Visa
        Supported Credit Cards: American Express, MasterCard, Visa
         
        This field is for validation purposes and should be left unchanged.

        If you have any questions or would like more information regarding recertification please contact us