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CCPA recommends that Referees complete this form and submit it directly to CCPA. Once a reference is received by CCPA, it
cannot be redacted or withdrawn. Please note that references can be accessed by applicants with the referee’s consent or
through the Privacy Act and Personal Information Protection and Electronic Documents Act.

References must be provided by graduate-level counsellors, supervisors or counsellor educators who can speak to the
applicant’s counselling competencies within the last ten years. The referee must be in a non-compliant relationship with the
applicant. All applicants must provide two reference forms with their application. PATHWAY TWO applicants must provide one
reference from a clinical supervisor who has engaged in formal supervisory activities according to CCC criteria and can speak to
the applicant’s counselling competencies.

INCOMPLETE FORMS WILL NOT BE PROCESSED

CCC Reference Form

"*" indicates required fields

1. Applicant Information

Name*
Address*

2. Referee Information

Referee Name*

During what time frame were you familiar with the applicant's counselling skills? (mm/yy - mm/yy)*

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3. Professional Relationship with Applicant

In what capacity did you know the applicant? Please check all that apply.*
Is there any reason that you should not be considered an appropriate reference? (Please consider any dual relationship, role conflict, overlapping roles, personal relationship, conflict of interest, supervisee, lack of knowledge of applicant's clinical work as a counsellor, outdated knowledge of applicant skills, etc).*

4. Supervision

Only individuals listed as supervisors in Section 3 must complete this Section
Did you have 4 years of post-graduate counselling experience when you supervised the applicant?
Please indicate how often supervision with the applicant took place (check the box below that applies):
What types of supervision did you provide to the applicant (check all that apply):

5. Evaluation of Professional Counselling Competencies

Based on the CCPA Code and Standards, individual, couple/family or group counselling competencies must be evaluated

6. Recommendation

I recommend this applicant for certification as a Canadian Certified Counsellor:*

7. Attestation

*
Do you have any concerns about the applicant's fitness to practice, including but not limited to concerns about their ethical and competent practices (any concerns that you are aware of will be disclosed to the Registrar)?*
Are you aware of any concerns about the applicant's fitness to practice raised by other educators, clinical supervisors, administrative supervisors, clients or other individuals involved in the applicant's practicum training (any concerns that you are aware of will be disclosed to the Registrar)?*
If a digital signature is provided by the reference, the form must be sent to CCPA directly from the individual who has provided the digital signature by email.
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