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2.17 Step One: Verification Report (Provisional Supervisor-Educator) ©

(Document completed by Verifier. Verifier may be RAC or someone appointed by the RAC.)

Personal Information: (please type or print)
Candidate Legal Name:
Email:
Admission Being Requested: (check one only)
CPE Provisional Supervisor-Educator
PCE Provisional Supervisor-Educator
Verifier (print name):
Date Verifier Assigned: / Date Materials Received:

Confirm that the candidate has submitted the required documents

for Provisional Supervisor-Educator application.

[Section IV, B for both CPE & PCE]

X / # / 4.  Required Documentation to be submitted to RAC:
Form 2.16 Application for Provisional Supervisor-Educator (PSE)
4.1 / A receipt of the application fee submitted to CASC National Office.
4.2 / Evidence of current membership within CASC.
4.3 / A copy of the candidate’s Certificate as a Spiritual Care Practitioner or a Psycho-Spiritual Therapist.
A signed copy of the Step Three Report of candidate’s certification process.
4.4 / Evidence of the completion of the graduate course in Adult Education or Supervision Theory from an educational institution accredited by the Association of Theological Schools (ATS) or The Council for Higher Education Accreditation (CHEA) or the Association of Universities and Colleges of Canada (AUCC).
4.5 / Evidence of current endorsement (within last five years) by a recognized religious faith group. (See Section VI)
4.6 / Evidence of good standing in a faith community (within the last five years) affiliated with your chosen religious tradition (Section VI).
4.7 / Three Letters of Reference from persons who have experience of or knowledge about the candidate’s practice of spiritual care or pastoral counselling which gives evidence of the satisfactory practice.
Reference 1 from a professional colleague:
Reference 2 from a colleague in another professional discipline:
Reference 3 from a Certified Supervisor-Educator in the candidate’s stream:
4.8 / A resume or curriculum vitae documenting pastoral experience, formal and alternative educational formation and personal & professional development.
4.9 / Description of participation in the organizational life of CASC (Section VII).
4.10 / The letter from the CASC Certified Supervisor-Educator under whom the candidate will be studying to confirm his/her willingness to provide supervision.
4.11 / Declaration of another provisional supervisor-educator to form a peer mentoring group while preparing for provisional status, conducting the SPE unit, and to foster evaluation of the experience. Option to meet in person, by phone or via video-conferencing on a monthly or bi-monthly basis.
·  May contact the ESC (certification chair or the accreditation chair) to obtain names of available provisional supervisor-educators.
X / # / Professional Papers required with application for Provisional Supervisor-Educator.
(Completed papers to be submitted to RAC only to be verified that they are completed, but they are read and assessed by the assessor and not by the RAC.)
5.1 / An autobiographical statement (3 to 5 pages) outlining personal and relational history and education, and influences which have shaped one's personal and professional functioning, with particular attention paid to personal dynamics.
5.2 / A paper (10 to 15 pages) giving attention to each of the following categories:
a. A philosophy of SPE including a discussion of the educational, theological, psychological, sociological and ethical framework which will guide the candidate's developing theory of supervision.
b. A statement of what the candidate considers important for effective program management, individual and group supervision.
c. A statement concerning the candidate’s professional vocational goals.
5.3 / A bibliography of candidate’s reading within the last year.
Admitting Processes (Provisional Supervisor-Educator)
Date the Formal Documents are approved:
Date & Means by which Candidate, Assessor and Supervisor-Educator are Notified:
Assessor:

If not approved, check one only:

Once the recommendations have been addressed, the candidate may re-activate this application by submitting the required documents, no later than:
The application is denied. Once the recommendations have been addressed, the candidate may submit a new application. At that time, the candidate must submit this form with the Formal Documents as one of the "previous Admitting or Certification reports."

Check one only:

A self-addressed stamped envelope was enclosed, and the candidate's materials are being returned.
No self-addressed stamped envelope was enclosed, and candidate's materials will be shredded on(date):
RAC Chair (print):
RAC Chair Signature: / Date:

Revised October 2017 Posted December 2017, 2.17 Page 1 of 2