This renewal of your NSCCT Membership is due on or before APRIL 1, 2015.

·  You are encouraged to send your renewal into the office as soon as possible.

·  A “How To” form is provided in the members only section of the NSCCT website. Please read the “How To” as it contains additional detail to assist you in completing this renewal accurately.

·  Please provide FULL AND COMPLETE INFORMATION this year as we need to confirm the accuracy of our database going forward following a recent computer crash.

·  Please supply all documentation to avoid a delay in processing your renewal.

·  This form is designed for completion by typing and then printing the completed form before signing the completed form for mailing. If you wish to hand write your responses, a fillable response renewal form is available on the NSCCT website in the Members Only section with more space for handwriting your responses. Please choose which format you wish to use before starting to fill out your renewal form. We hope this will elliminate cramped or illegible hand writen responses.

A. MEMBER INFORMATION:

Salutation: ____ Name: ______Reg #: ______-__ - __ __ - ______

Street /PO Box:______City, Town, etc:______

Prov:_____ Postal Code ______Email: ______

Telephone: Home # ______Work # ______Cell#: ______

Master’s Degree:_____ Major: ______Degree Conferred: M _____/Yr ______

Institution:______City: ______Prov/State ______

Country: ______Institution’s Website: ______

Language Proficiency: Please indicate all languages in which you can provide Counselling Therapy for a client.

EnglishFrench Sign Other: ______

(If Registrar is asked to supply names of practitioners with my language abilities, I agree to allow my name/contact information to be included in such communication. Initial here ____ )

B. MEMBERSHIP STATUS: Choose ONE of the TWO categories below that describes your current activity as a Registered Counselling Therapist _____ or Registered Counselling Therapist - Candidate: _____

C. SCOPE OF PRACTICE: (Refer to ‘How to..’ guide) ______

______

______

D. POPULATION: (Refer to ‘How to..’ guide) ______

E. EMPLOYMENT: (Please complete all that apply to your practice as a Counselling Therapist. )

My current employer is ______

located at the following address: ______.

My Position Title is: ______

and I work with the following client groups: ______.

I have my own private practice in the community of ______

My practice is registered under the name: ______

and is located at the following address: ______

My business website and/or business email: ______

F. CONTINUING EDUCATION CREDITS:

Membership renewal requires that during each licensing year, a minimum of 12 hours of Continuing Education Credit Hours be taken and approved through CCPA. * Refer to attached “How to” guide for specific instructions regarding this document before entering your response – particularly if you are a newly approved RCT-Candidate.

Please complete the following: I have earned ______Continuing Education Credit Hours between April 1, 2014 and March 31, 2015. If applicable, complete the following: ______hours, previously unused, are carried over from the previous licensing year.

I am enclosing a CEC transcript from CCPA verifying this achievement. Initial here: ______

G. PROFESSIONAL LIABILITY INSURANCE: The NSCCT Board requires each practising, registered member to carry, as a minimum, $1,000,000 in Professional Liability Insurance. Members must investigate the appropriate coverage for their particular practice needs. (Check all that apply, initial where required, and enclose documentation where requested to do so.)

Private Practitioners: Send the cover sheet for your policy indicating the expiry date and coverage. Ensure you continue to send updates to your policy whenever it is renewed.

School Counsellors: Check with your School Board head office to determine their protocol for providing Insurance certificates from the School Insurance Program (SIP). Enclose a copy of the insurance cover page with your name on it.

NSCC Counsellors: Contact your Human Resources department for their protocol to provide insurance certificates from the School Insurance Program (SIP). Enclose copy of document with this renewal form.

RCT’s or RCT-C’s employed in other workplaces/institutions: Send a copy of the policy cover sheet covering your professional liability insurance. If your name does not appear on this policy document, in addition to sending the cover sheet , enclose a letter from your employer, on company letterhead, verifying your inclusion in the enclosed policy.

I have no Professional Liability Insurance at present as I am not currently practising as a Registered Counselling Therapist or Registered Counselling Therapist-Candidate. I acknowledge that I may not engage in counselling practise without ensuring that I have professional liability insurance coverage before beginning to practise, whether it is on a part-time or full-time basis. Once my status changes, I must report this change immediately to the Registrar.

By signing below, I acknowledge that I have read and understand the above statement regarding professional liability insurance responsibilities.

Signed: ______

H. MEMBERSHIP FEES: Please enclose the following:

CHEQUE MONEY ORDER

Amount:

(made payable to the ‘Nova Scotia College of Counselling Therapists’ )

(If renewal is not postmarked on or before April 1, 2015 an additional $75.00 late fee must be submitted with this renewal.)

______

I. DECLARATION:

Kindly answer all questions by checking the ‘yes’ or ‘no’ box next to each one. Then sign and date in the space provided below which will confirm the responses you have made.

Unsigned applications cannot be processed.

Have you, since your previous membership renewal with NSCCT:

(1)  been investigated, charged or convicted of a criminal offence ? (If so, provide details)
(2)  had a finding of, or are you facing a proceeding of professional misconduct, incapacity, or incompetency filed against you in Nova Scotia or another jurisdiction? (If so, provide details)
(3)  been registered to practise as a Counselling Therapist, or similar / equivalent professional designation, in other provinces or countries? (If so, provide copy of registration / membership card.)
As a member of the Nova Scotia College of Counselling Therapists (NSCCT), I agree that NSCCT is authorized to collect, utilize and disclose personal information regarding my status within NSCCT and any other information required to comply with NSCCT’s mission of protecting the public. I affirm that all information provided to NSCCT is accurate both in this form and in any attachments I may provide. As a member of the NSCCT, I hereby pledge to abide by the ‘Code of Ethics’ and ‘Standards of Practice’ of the Canadian Counselling and Psychotherapy Association.*
*As per Section 41(1) of the NSCCT By-Laws, the Code of Ethics and Standards of Practice adopted by the College are the CCPACode of Ethics and Standards of Practice.
Signature: ______Date: ______ / Yes
Yes
Yes
/ No
No
No

RETURN COMPLETED APPLICATION with your:

·  C E Hours transcript (from CCPA)

·  verification of insurance coverage, and

·  payment to:

NSCCT_2015-2016_ Registered Members Renewal please complete all pages Page 2 of 3