Psychological Assessment Request Form
The Virginia Conference UMC works in coordination with the Virginia Institute of Pastoral Care (VIPCare) to conduct psychological assessments. These assessments are required at various point as part of various application processes. Fill in the information below and VIPCare will follow up with you for next steps.
Legal Name
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First Name
Last Name
Preferred Name
First Name
Last Name
Date this request was submitted:
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Month
-
Day
Year
Date
Candidate's Date of Birth
*
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Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What level Psyc Assessment are you requesting?
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Tier 1 for those in the Candidacy process, Licensing Process, Provisional Application Process, Transfer Application Process
Tier 2 for those applying for Full Membership, Associate Membership, Recognition of Orders
I am requesting this Psychological Assessment as I am applying for:
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Please Select
Candidacy
Licensing
Provisional Membership
Associate Membership
Ordination as Deacon
Ordination as Elder
Recognition of Orders
Transfer to the Virginia Conference UMC
Next Steps and Payment Information
Within two weeks of receiving this request a member of the VIPCare staff will reach out to you so you can complete your assessment. Upon completing your assessment you are responsible for sending a payment of $200 to VIPCare at the address below: Virginia Institute of Pastoral Care 2000 Bremo Rd. Suite 105 Richmond, Virginia 23226
Signature: By signing below you are agreeing to submit payment once you complete your assessment.
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Thank you for sending in this psychological assessment request.
If you do not hear from VIPCare in two weeks contact them at 804-282-8332 for an update.
Submit
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