Certified Pastoral Counselor Application - 1

Certified Pastoral Counselor Application - 1

AMERICAN ASSOCIATION OF PASTORAL COUNSELORS

CERTIFIED PASTORAL COUNSELOR APPLICATION

(Please PRINT/TYPE all information clearly)

Date AAPC Member No. .

(If applicable)

I.PERSONAL

Name

(Last) (First) (Middle)

Official Mailing Address:

(City) (State) (Zip)

Phone Numbers (indicate whether office (o) or home (h) :

Primary Secondary

Fax No: E-mail Address:

Date of Birth Gender Faith Community

Race: (For Demographics)

Caucasian _____ African American______Asian______Hispanic______Other______

Highest degree achieved Current membership level in AAPC

Have you ever been under disciplinary action by any professional organization or licensing board, or have you ever had a felony conviction? YES NO If yes, please attach a brief description of the issue and the action taken.

II.CURRENT PROFESSIONAL COUNSELING POSITION AND RESPONSIBILITIES

A.Primary Position:

Name of Church/Synagogue/Mosque/Agency or Private Practice:

Position/Title How long?

Address:

Telephone: If Agency, who sponsors it:

To whom are you responsible?

Description of your work:

Additional counseling positions and responsibilities including the name of institutions/agencies:

B.Total hours per week spent as follows:

1.Counseling:

Individual: Family: (Couple , 3 or more members ) Group:

2.Administration: Nature of and hours:

3.Teaching: Institution:

4.Course(s) taught and hours:

5.Pastoral Ministry (other than the above):

Institution, nature of ministry and hours:

1. RELIGIOUS ENDORSING BODY AND PASTORAL MINISTRY (Applicable only for Ordained Faith Leaders):

A.Religious Endorsing Body:

Ordination/Consecration/Endorsement: Date:

By Whom:

Where is your current status officially recorded?

Submit CURRENTEndorsement Body Endorsement form, using attached form provided for this purpose.

B.1.Describe your present professional participation in your Religious Endorsing Body (if applicable):

2.List prior pastoral responsibilities (if applicable):

C.Submit a letter from the appropriate office of your localfaith community (usually the local Church/Congregation/Synagogue/Mosque) stating that you hold an active relationship to that religious community.

D.1.Pastoral Identity Statement: Attach a 1,000-word statement addressing the strengths and weaknesses of your pastoral ministry and your understanding of your pastoral identity. Include information about relevant congregational experiences, pastoral aspects of your current clinical ministry, and how you presently claim the authority of your pastoral identity.

2.Service in Ministry Statement: Attach a brief written description of service in ministry to your Religious Endorsing Body or endorsement community during the past three years.

IV.ACADEMIC PREPARATION

A.College

Degree Year Major

B.Seminary

Degree Year Major

C.Graduate:

Degree Year Major

Title of Thesis/Dissertation:

NOTE:Include one official transcript (in sealed envelope from school) for all claimed credits and degrees from accredited schools. Transcripts may also be sent directly to the Association Office. If previously submitted, please make a note of this.

D.Additional Professional Education: (List names and addresses of institutions, dates of study and courses)

V.PASTORAL CARE PRACTICUM: (most common experience is a unit of Clinical Pastoral Education)

Name and Address Accrediting Agency Dates and Hours

of Institution Supervisor(s) per week

Required

Unit:

AdditionalUnits:

List below the name and address of the supervisor of your self-reflection pastoral experience, whose evaluation you are including in your application.

Name

Address

NOTE:Attach Supervisor's and applicant's evaluations of most recent experience or latest unit of CPE, or if these are not available, a letter verifying satisfactory completion of that unit from the institution at which it was obtained.

VI.PASTORAL COUNSELING and SUPERVISION EXPERIENCE

A.Details of Pastoral Counseling:

Hours of Supervision

Counseling Hours Dates Supervisor(s)Individual ----- Group

Individual:

Couple:

Family:

Group:

Other (describe):

TOTAL Counseling Hours: TOTAL Supervised Hours:

Certified Pastoral Counselor Application - 1

B.Details of Required Categories of Supervision

Standards for the Certified Pastoral Counselor category are a minimum of 125 supervisory hours and a minimum of 375 counseling hours. Indicate on the chart below, the number of counseling hours delivered and supervision hours received in each supervisory category.

Hours of Hours of

Category Supervisor Counseling Supervision

1.Individual - 60 hours

(at least 30 hours with

one supervisor)

2.Continuous Case

Conference - 35 hours

4.Interdisciplinary

Case Conference -

30 hours

1. “One-third Rule”

You are required to have one-third (42 hours) of your required supervisory hours with an AAPC Diplomate, Fellow (under supervision of supervision), or from an AAPC approved Training Program in Pastoral Counseling.

I have met the one-third rule and have a minimum of 42 hours of supervision with an AAPC Diplomate, Fellow (under supervision of supervision) or from an AAPC approved training program. Yes No, please explain.

1. Supervisors Evaluations

Attach evaluations from three supervisors approved by your Regional Certification Committee (one of whom should be a supervisor listed in category B. 1. above). All supervisors should be able to attest to the quality of your current work. These evaluations are to be completed using the forms and instructions attached to this application.

Supervision by a Fellow or Diplomate or as part of an AAPC Training Program in Pastoral Counseling does not require prior approval of supervisors. Other supervisors do require prior approval by Regional Certification Committee. Submit copy of Committee’s approval. Forms are available from the Association office or see Appendix D.

Name (1)

Name (2)

Name (3)

E.Current Ongoing Supervision

Name of Supervisor:

Supervisor's AAPC Certification when supervision began:

Diplomate Fellow (when under supervision of supervision)

If Fellow, Name of supervising Diplomate:

If nonAAPC, Profession

(Include a copy of Regional Certification Committee approval; form available from Association office.)

Supervisory Contract:Frequency of Sessions:

Focus of Supervision:

Duration of Contract:

F.Work Sample

NOTE:Do NOT include the following documentation of your work sample with this application. The Chair of the Regional Certification Committee will advise you when and to whom this is to be sent.

a.An Audio or video tape recording or case study of the applicant's counseling and write up prepared according to the guidelines in the Membership Manual, Appendix B.

b.A statement on the theological/spiritual dynamics using the guidelines in the Membership Manual, Appendix B.

VII.ADDITIONAL PROFESSIONAL DATA (List professional memberships, associations, affiliations, publications, with dates.)

VIII.AAPC LEADERSHIP

Considering the mission of AAPC and the reality that ours is a volunteer community,

• How are you hoping the organization will help facilitate your growth?
• How would you like to see yourself involved?
• What do you feel you would like to bring to the community?

______

IX.STATEMENT OF COMPLIANCE

I understand the responsibilities and obligations of membership in the American Association of Pastoral Counselors and agree to abide by its Code of Ethics, and to pay dues and submit reports as required to remain in good standing.

I have read, sought consultation and understand the requirements for Certified Pastoral Counselor as presented in the Membership Manual.

I also understand that personnel of the Association will review and act upon this application, and I agree to hold such personnel, the Association, and its officers and agents harmless with respect to action they may take in connection with such review.

I also understand that the processing fee is nonrefundable.

Date Signature

ATTENTION: HAVE YOU . . . .

1.CHECKED THIS APPLICATION TO ENSURE ALL REQUIRED DOCUMENTATION HAS BEEN INCLUDED?

2.PREPARED TWO SETS (collated, no staples) OF THE APPLICATION AND ALL DOCUMENTATION?

(Keep one for your records.)

Updated: 05/14/14

AMERICAN ASSOCIATION OF PASTORAL COUNSELORS

SUPERVISOR'S EVALUATION of CERTIFIED PASTORAL COUNSELOR APPLICANT

APPLICANT:

(Name and Address)

SUPERVISOR:

My supervisor has my permission to use any material regarding me, which he/she feels appropriate.

(Date) (Applicant's Signature)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

FROM SUPERVISOR:

NOTE: This form is to be returned with your evaluation to the applicant to be included with his/her application to the American Association of Pastoral Counselors.

SUPERVISION OF PASTORAL COUNSELING:

1.Dates of Supervision: FROM TO

2.Number of Supervisory Hours:

a. Individual b. Group c. Interdisciplinary .

CERTIFICATION AND BACKGROUND OF REPORTING SUPERVISOR:

1.AAPC Certification at the time supervision began:

2.If Fellow, name of supervising Diplomate:

3.If non-AAPC: I hold the degree from

(Name of institution)

and I am certified at the

level by .

(Name of professional organization)

(Date) (Supervisor's Signature)

1/02

Certified Pastoral Counselor Application - 1

AMERICAN ASSOCIATION OF PASTORAL COUNSELORS

SUPERVISOR'S EVALUATION of CERTIFIED PASTORAL COUNSELOR APPLICANT

PURPOSE OF EVALUATION: Through your written evaluation you join with the Certification Committee of the Association as colleagues sharing a mutual concern for the preparation of persons for the ministry of pastoral counseling. This evaluation is intended to assist the Certification Committee in assessing the applicant and assuring that Principle V, D of the AAPC Code of Ethics (“We advise our students, supervisees and employees against offering or engaging in, or holding themselves out as competent or engage in, professional services beyond their training, level or experience and competence.”) is adhered to. When we receive three supervisors’ evaluations along with other documentation of having met the required standards, the regional Certification Committee will plan to meet with the applicant for a consultative interview and welcome him/her as a Certified Pastoral Counselor in AAPC. Therefore, THE SUPERVISOR IS TO MAKE AN ASSESSMENT AS TO THE APPLICANT’S READINESS FOR CERTIFIED PASTORAL COUNSELOR BEFORE WRITING AND SENDING THIS EVALUATION.

TO SUPERVISOR: (ON YOUR LETTERHEAD) PLEASE COMMENT FULLY ON THE FOLLOWING, AND ATTACH TO ENCLOSED FORM.

I.Evaluation of Learning Pastoral Counseling:

Describe the applicant's learning style and issues within the supervisory process of learning pastoral counseling. Include critical incident reporting. (Append learning contract)

II.Professional Development as a Pastoral Counselor:

A.Assess the applicant's awareness of self, of internal dynamics and interpersonal relationships, and capacity for flexible and effective relatedness to others, plus ability to use supervision and claim personal and professional authority.

B.Assess the applicant's ability to integrate pastoral identity into the pastoral counseling process and see the pastoral role in its religious and interprofessional contexts.

C.Assess the applicant's understanding of and assent to the AAPC Code of Ethics and related standards of professional ethics including the maintenance of confidentiality and maintenance of appropriate therapeutic parameters as well as commitment to such basic values as respect for the worth and rights of persons.

III.Theory and Practice of Pastoral Counseling:

A.Assess the applicant's knowledge of theology and behavioral sciences as to integration at both theoretical and operational levels. Specifically, assess the applicant's capacity to develop theory which is congruent with clinical practice, and which demonstrates theoretical awareness of the major areas of pastoral counseling, i.e. history of health and salvation, the traditions of pastoral care and pastoral counseling, personality and developmental theory, psychopathology, marriage and family dynamics, variation of therapeutic modalities.

B.Assess the applicant's capacity to understand the theological grounding of the counseling process within the counselor and counselee.

C.Assess the applicant's capacity to establish a therapeutic relationship; i.e. evaluate therapeutic need, develop treatment plan, assess therapeutic process consistent with applicant's theoretical orientation. Include the applicant's capacity to assess own strength and weakness in the treatment process.

D.Assess the applicant's knowledge of legal issues in the practice of pastoral counseling, i.e. legal status of clergy in state where practicing, requirements for reporting lifethreatening and child/sexual abuse situations, and confidentiality.