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CCPA-ACCP
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Basic CCC Eligibility Assessment (TEST)
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INCOMPLETE FORMS WILL NOT BE PROCESSED
Basic CCC Eligibility Assessment
"
*
" indicates required fields
1. Applicant Information
CCPA Member #
*
Name
*
First Name
Last Name
Other Legal Names
Address
*
Street Address
City
Province
Postal Code
Email
*
Home Phone
*
Work Phone
*
2. Education
Must hold graduate degree in counselling or related field
Graduate Degree(s)
*
University
Year
Degree
Major
Add
Remove
Graduate Degree(s)
3. Graduate-level coursework toward certification
Located on transcript(s), minimum 8 full courses
Course Code
*
Counselling Theory
(Compulsory)
Semester Completed
*
Course Code
*
Supervised Counselling Practicum/Internship
(Compulsory)
Semester Completed
*
Course Code
*
Counselling and Communication Skills
(Compulsory for graduates after Sept 2012)
Semester Completed
*
Course Code
*
Professional Ethics
(Compulsory for graduates after Sept 2012)
Semester Completed
*
3. Elective Courses
Please refer to the corresponding section in the Certification Guide
Course Code
*
Course Title
*
Semester Completed
*
Course Code
*
Course Title
*
Semester Completed
*
Course Code
*
Course Title
*
Semester Completed
*
Course Code
*
Course Title
*
Semester Completed
*
Course Code
Course Title
Semester Completed
Course Code
Course Title
Semester Completed
4. Supporting Documentation
A copy of your transcript and course descriptions must be submitted with your application; please see the corresponding section on the Certification Guide. In addition, please identify which additional documentation you wish to provide for evaluation by the Registrar.
CCC Practicum Form(s)
One form per practicum placement.
CCC Work Experience Form(s)
One form per employer/workplace. Letter(s) from employers may also be a suitable alternative if they describe the nature of work and number of hours of employment.
TWO CCC Reference Forms (optional)
Completed, signed, and submitted by clinical references. Note: If you are a Pathway 2 applicant, one reference must be from a clinical supervisor.
Resume / CV
Other (please describe)
5. Attestation
Please read carefully for important information regarding your application
I certify that the information provided in this application is accurate and complete to the best of my knowledge and belief. I understand that the outcome of my application depends upon my demonstration of how my application satisfies the required criteria, including presenting relevant coursework in Section 3 for consideration by the Registrar. I will practice in accordance with CCPA’s Code of Ethics. I have included a valid criminal records check with vulnerable sector screening conducted within the last 12 months or will submit one to CCPA shortly. I understand that any certification granted to me by the Canadian Counselling and Psychotherapy Association does not in and of itself specify licensure to practice counselling for a fee, monetary or otherwise. If I am granted certification by CCPA and practice counselling as a private practitioner, I do so at my own risk. I hereby release CCPA from any and all liability and/or claim that may arise from any decisions to practice privately as a Canadian Certified Counsellor. For research and statistical purposes only, data resulting from my participation in this process may be used in an unidentifiable manner. I understand that all material becomes the property of CCPA upon receipt and that originals will not be returned to me, with the exception of the Criminal Records Check (if requested by the applicant).
Applicant's Signature
*
Date
*
MM slash DD slash YYYY
6. Payment
Payment can be made online by logging into the Member Portal at https://members.ccpa-accp.ca. The total cost for this application is $40.