1. Applicant Information Name *
First Name Last Name Address * 2. Employment Site Information 3. Applicant's Practice Briefly describe the characteristics of the clientele and the nature of individual, couple or family counselling interventions provided by the applicant * 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 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.