PATHWAY TWO: Work Experience Form (TEST) - Canadian Counselling and Psychotherapy Association

This form may be accessed by applicants under the Freedom of Information Legislation.
This form is intended for applicants following PATHWAY TWO. It documents an applicant’s counselling work experience within
the last five years. Please submit one form per employer. A definition of counselling and scope of practice is available on CCPA’s
website.

INCOMPLETE FORMS WILL NOT BE PROCESSED

CCC Work Experience Form

Pathway TWO

"*" indicates required fields

1. Applicant Information

Name*

First Name Last Name

Other Legal Names

Address*

Street Address City Province Postal Code

Email*

Home Phone*

Work Phone*

2. Employment Site Information

Agency or Institution Name*

Number and Street*

City, Province, Postal Code*

Manager or Supervisor*

Phone*

Email*

3. Applicant's Practice

Applicant's Position Title*

Dates of Employment (mm/yy – mm/yy)*

How many hours a week was the applicant employed?*

Approximately how many counselling sessions did the applicant provide each week?*

What was the duration of each session?*

What is the total amount of direct client counselling hours you provided during your employment within the last 5 years?*

Briefly describe the characteristics of the clientele and the nature of individual, couple or family counselling interventions provided by the applicant*

What is the total amount of group counselling hours you provided during your employment within the last 5 years?*

Briefly describe the characteristics of the group clientele and the nature of the group counselling interventions provided by the applicant:*

Please summarize the amount of time (in the form of a percentage or number of weekly hours) the applicant spent engaging in various activities during this employment.

Direct Counselling Hours

Indirect Counselling Hours

Intake*

Case and File Management*

Counselling Sessions*

Supervision*

Groups Counselling*

Consultation*

Assessments*

Other Activities (Please describe)

4. Attestation

I attest to the accuracy of this information. I am willing to answer additional questions concerning this evaluation if CCPA deems it necessary. I understand and consent to be contacted in follow-up to the provided information on the CCC Work Experience Form.
The applicant and employer must co-attest to the accuracy of the information. In the case of individuals in private practice, the CCC Work Experience Form must still be signed by a professional at arms‐length who can speak to the truth and accuracy of the information being provided; self‐attestation by the applicant is not sufficient.

*If a digital signature is provided by either the employer, the the form must be sent to CCPA directly from the individual who has provided the digital signature by email.

Applicant's Signature*

Date*

Name of Employer

Employer's Signature*

Date*