Chapter Certification Report Form
The purpose of this form is to provide the Certification Review Panel with a Chapter’s recommendations of a candidate for certification, according to CPSP Standards.
NOTE: This form should only be used for candidates who are recommended for certification, and who have completed the Initial Phase of the Certification Process.
Instructions:
This form should be completed by the candidate’s Chapter convener – OR – by the convener of Chapter assisting with the candidate’s initial review (for candidates from chapters without a critical mass to conduct a certification review.)
Please save the completed to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – Chapter Certification Report Form” or “Hernandez – Chapter Certification Report Form”.
Send the completed form to Krista Argiropolis, Administrative Coordinator (), and please keep a copy for your records.
Today’s date: / Check certification(s) candidate is seeking:Diplomate Supervisor
Diplomate Psychotherapist
Pastoral Counselor
Clinical Chaplain
Hospice & Palliative Care
Associate Pastoral Counselor
Associate Clinical Chaplain
Associate Hospice & Palliative Care
Clinically Trained Minister
Candidate’s Name:
Candidate’s Chapter:
Convener:
Date of Meeting with Chapter to Review Certification Materials:
Candidate’s Chapter has at least four certified members of the chapter holding the same certification the candidate seeks? Yes No
If No, name of Chapter assisting candidate in the process?
Name of Person Submitting this Form: Email:
Please report the impressions of the candidate in the following categories.
Quality of Written Materials
Briefly describe how the candidate integrates their personal theory and theology into clinical practice. Are the written materials congruent with their person and developmental history, etc.?
Clinical Functioning
Briefly describe how the candidate demonstrates their ability to integrate their theory, theology, and unique personal history in their clinical practice.
Theoretical Comprehension
Report your assessment of the candidate’s demonstrated proficiency, Competencies and skills required for the level of certification for which he/she is applying. Your assessment of the candidate’s knowledge of the core bibliography, including, but not limited to: crisis intervention theory and practice; grief and loss; interdisciplinary and interfaith pastoral care.
Ethical Commitment
Evidence of high ethical commitment, including absolute respect for the worth and rights of persons. Please provide the recommended growth/developmental edges of the candidate reviewed.
Equivalencies (if applicable)
Equivalencies for education or training requirements should be substantively similar to the stated requirement for the desired certification. The acceptability of equivalent training or education will be determined by the Candidate’s Chapter or Proxy Chapter, subject to the review of the Certification Committee Team and the Leadership Team.