Certification Consultation Report for

Supervisor-in-Training (SIT) or

Training Supervisor (TS) Program

This form is be completed by an appointed member of the Certification Committee’s Consultation Panel.

Please save the completed form to your computer, and place the candidate’s last name in the name of the file. For example: “Jones – Certification Committee’s Report Form”

Send the completed form to Krista Argiropolis, Administrative Coordinator (), the Candidate and please keep a copy for the Certification Committee’s records.

Section 1.

1.1 / Today’s Date:
1.2 / Candidate’s Name:
Please type it exactly as it should appear on the certificate or Directory
1.3 / Candidate’s Chapter:
1.4 / Candidate’s Email:
1.5 / For SIT’s -- Training Supervisor’s Name:
For SIT’s -- Training Supervisor’s Email:
1.6 / For TS’s -- Training Supervisor’sName:
For TS’s -- Training Supervisor’s Email:
1.7 / Convener’s Name:
1.8 / Convener’s Email:
1.9 / Select the category the candidate seeks:
Authorization to begin as a Supervisor in Training
Authorization to begin as a Training Supervisor
Training Supervisor
Note: For those seeking authorization to begin as an SIT the chapter must have at least four Diplomates or four authorized SITs. Likewise for authorization to begin as a Training Supervisors in Training must have at least four members present for the consultation who are Diplomates under the 2016 Standards or have functioned as a Diplomate for at least 5 years under the previous Standards or four members who have been authorized as Training Supervisors in Training.
1.10 / Name of Chapterproviding the consultation:
Note: For consultation with those seeking to begin as SIT the chapter must have at least 4 SITs who have been approved to begin SIT training or 4 Diplomates. Likewise, for authorization to begin as a Training Supervisor the chapter must have at least four members present for the consultation who have been approved to begin as Training supervisors under the 2016 Standards or at least four Diplomates who have been certified for at least five years under the previous Standards.
1.11 / Date of consultation with the qualified Chapter:
1.12 / Chapter members present for the consultation (list):

Section 2.

2.1 / Ethical and CPSP Commitment
Evidence of high ethical commitment, including absolute respect for the worth and rights of persons.
Level of commitment to CPSP’s mission and Standards as a means to provide an exceptional CPE training program that represents CPSP well in the public domain.
RESPONSE:
2.2 / Written and Video Materials
From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of CPE Supervision. Are the written materials well organized and reflect a graduate level of professionalism? Critique the strength and weakness of candidate’s ability to provide Clinical Pastoral Education training as demonstrated by the required materials?
RESPONSE:
2.3 / Demonstrated Competency
Describe how the candidate was able (or not able) to demonstrate during the face-to-face certification review process congruence between their submitted materials and their ability to integrate theory, theology, unique personal history and use of self in their clinical practice of CPE supervision? What were the strength and weakness of the candidate during the give-and-take process of the consultation?
RESPONSE:

Section 3.

3.1 / Supporting Materials for Review
Authorization to begin as an Supervisor In Training:
A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of clinical pastoral supervision.
A projected theory of supervision document outlining the theories you are considering in your work as an Supervisor In Training. (It is understood that this is not a comprehensive theory paper as that will develop through the candidate's training)
A detailed clinical case that reflects one's pastoral competency and clinical acuity along with the candidate's analysis of the case.
Final evaluations from self and supervisor of the candidate's final unit of CPE.
Authorization to begin as a Training Supervisor in Training:
A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of clinical pastoral supervision.
A projected theory of supervision document outlining the theories you are considering in your work as a Training Supervisor in Training(It is understood that this is not a comprehensive theory paper as that will develop through the candidate's training)
A detailed clinical case that reflects one's pastoral competency and clinical acuity along with the candidate's analysis of the case.
Final evaluations from self and supervisor of the candidate's final unit of CPE.
See CPSP Standards, V.16, approved 16-Mar-2016.

Section 4.

4.1 / Recommendation
Did the Certification Committee grant or deny the Candidate’s request to enter a program of training as a Supervisor-in-Training or Training Supervisor?
Yes No
If denied, pleased state why and list the areas of needed growth and development.
If the candidate is granted entry into a program of clinical supervision leading to certification, please provide comments that reflect on their continued growing edges:
RESPONSE:

Candidate’s Signature: Date:

Convener’s Signature: Date:

Supervisor’s Signature: Date:

Cert Form – Consultation Report for SIT/TSPage 1 of 5