Membership Application Associate Professional Counsellor (APC)

In addition to meeting all entry level membership requirements for Certified Professional Counsellor (CPC) membership. CPC's have completed additional post-graduate experience including a minimum of 500 directly client contact hours and 50 hours of Supervision with a qualified supervisor.

Application Document Checklist:

1. Transcript from your graduate or doctoral degree completed in relation to counselling, psychotherapy or other mental health field.

2. Resume/C.V.

3. Criminal/Vulnerable Persons Check (no more than 1 year old)

4. Completed liability insurance forms or provide proof of your own insurance which equals or is greater than $5,000,000 liability coverage

5. Have your references complete the online reference forms or submit by email to paccp@paccp.ca

6. If you answered yes to any of the Statement of Professional Ethics & Conduct question, please submit further explanation to our office.

7. If you are not curently a PACCP APC member and are strictly a NEW applicant, then you must also submit verification of your directly client contact hours and supervision hours, in the form of a log or signed letter from your Supervisor. Ensure you indicate the dates these hours were accumulated from. If there were more than one supervisor, please submit verification from each. These must be POST-graduate hours. IF you are a current PACCP APC member, you must complete the Certification Forms shared with you on our website. You do not need to fill out this application form.

8. Need a letter of verification from Supervisor(s) stating that they have taken a formal course in Supervision Fundamentals, and have had a minimum of 15 hours of Supervision of THEIR Supervision. This passes our "qualified supervisor" test.

Please email paccp@paccp.ca the following documents to be supportive of your application for membership or upload them in the appropriate sections of the application.

Please fill out the below information to submit your Certified Professional Counsellor (CPC) membership application to PACCP.

Last Name*

First Name*

MaleFemale

Age*

Certified Professional Counsellor (CPC)

MAILING ADDRESS (for PACCP office use only)

Street/Box Number*

City/Town*

Province*

Postal Code*

Phone Number (Daytime)*

Phone Number (Cell)

Email Address*

EDUCATIONAL INFORMATION

Please provide information in regards to your counselling or related field of education only.

Highest Level of Education (in relation to counselling)*

Degree or Specialization*

Institution*

YesNoUnsure

YesNo

YesNoOther

I have attached a transcript electronically below.I will be forwarding a transcript by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI have requested my school send PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email it to paccp@paccp.ca

Attachment (Please attached a copy of your transcript)

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VOCATIONAL & CERTIFICATION INFORMATION

Years of Counselling Experience

NoYesOther

How many hours a week do you work as counsellor?

I have attached an electronic copy of my resume/cv belowI will be forwarding this document by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email it to paccp@paccp.ca

Attachment (Please attach a current resume/cv)

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Name of Employer

Phone number of Employer

TOTAL Number of Direct Client Hours (minimum 500) - POSTGRADUATE*

TOTAL Number of Supervision Hours (minimum 50) - POSTGRADUATE*

Names of Qualified Supervisors and their Qualifications*

I have attached, or will email PACCP, a signed log of verification of post-graduate hours (minimum 500 hrs of client contact and 50 hours of supervision); should be signed by Supervisor(s) for verification purposes. May be summaried by year or month if more convenient.I have attached, or will email PACCP, verification of my Supervisor credentials either in the form of a letter from them, C.V., Professional Disclosure. Should indicate that they have taken a formal course in Supervision Fundamentals and have had a minimum of 15 hours of Supervision of their Supervision.

Attachment (Please attach above marked items or email to paccp@paccp.ca)

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REFERENCES

Please provide name, email address, relationship to you, and contact phone number for each reference. References submitted online are recommended/requested to speed up the approval process. However, they may also email a letter of reference to paccp@paccp.ca

Reference #1 Professional Colleague*

Attachment (if you have a written reference)

Select File

Reference #2 Clinical Supervisor*

Attachment (if you have a written reference)

Select File

Reference #3 Church Pastor or Leader*

Attachment (if you have a written reference)

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LIABILITY INSURANCE

YesNo

I have provided electronic copies of the liability insurance forms belowI will send the forms by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email the form to paccp@paccp.ca

Attach the Liability Insurance application form

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YesOther

I have provided electronic copies of the proof of insurance belowI will send proof of insurance by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email the proof of insurance to paccp@paccp.ca

Attachment (please provide proof of current insurance if you are NOT enrolling in PACCP's insurance policy)

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STATEMENT OF PROFESSIONAL ETHICS AND CONDUCT

YesNoOther

CRIMINAL RECORD CHECK

Please provide a copy of your Criminal Record Check; including Vulnerable Persons search (no more than a year old).

I have provided a copy of my criminal check, including Vulnerable Persons search, in electronic format belowI will send this document by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email this document to paccp@paccp.ca

Attachment (if providing electronic copies)

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MEMBERSHIP AGREEMENT

PACCP Statement of BeliefsPACCP Principles of PracticePACCP Code of EthicsAll other regulations and policies for PACCP members

I also give my permission for an authorized representative of PACCP to contact my supervisor or any other professional reference whom I have nominated to support this application, for verification purposes. I also affirm that the information provided in this application is accurate and true.

Signed*

Date*

Date

PAYMENT INFORMATION

You must make payment of your application fee of $50 now. This is a one time fee only.

Once all your documents are received, and your application is reviewed by the Applications committee, you will be notified that payment of the membership and insurance fee (if applicable) is now due. You will be sent an invoice which you may pay by credit card online at that time.

My Products

Application Fee$50.00CAD

One Time Application Fee due at time of application submission. This is non-refundable

Total $0.00CAD

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