Counselor Application for Board Certification

All information below must be filled out in full. A resume is unacceptable for the completion of any question on this application.

For more information or questions, email Julia@theopusonegroup.com or call (770) 429-1200.

Where the space provided is insufficient, attach additional sheets in the section at the end or email them to Julia@theopusonegroup.com along with an explanation.

Illegible, incorrect, or partially completed applications will be delayed until the problems are corrected.

Upon verification of all the enclosed information, we will be contacting you for a short oral interview (either in person or by phone).

The application is not considered complete until the non-refundable application fee is received.

Select the type of application you are applying for

Pastoral CounselorChristian Counselor

Enter your name exactly as you want it to appear on your membership card

First Name

Middle Name

Last Name

Degree

Street Address

City

State

State Abbreviation

Zip Code

E-mail Address

example@example.com

Telephone Number (Home)

Date of birth

Date

Last 4 digits of social security number

Have you ever served active duty in the Armed Forces, the Reserves, or the National Guard during wartime or during any conflict when military personnel were commissioned by the President?

YesNo

Upload a current picture here:

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Check all that apply:

OrdainedLicensed

Church Affiliation:

Denomination:

Are you currently employed by a church or ecclesiastical body?

YesNo

If yes, provide the name of the church and address:

Have you held a license/certification in any jurisdiction, at any time, as a professional counselor, marriage and family therapist, social worker, Christian counselor, and/or Therapist?

YesNo

List all professional Christian counselor and/or therapist licenses/certifications that you have held below:

	License 1	License 2
License/Certification Title
Jurisdiction
License/Certification Number
Date Issued
Expiration Date

Have you had a license/certification revoked, suspended, or annulled?

YesNo

Have you ever had a disciplinary action taken against you by the authority issuing the license/certification?

YesNo

Have you ever been refused renewal of the license pursuant to disciplinary proceedings?

YesNo

Attach an explanation along with a copy of the order or decree and any other relevant documents here

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Have you ever been the subject of disciplinary proceedings?

YesNo

Attach an explanation along with a copy of the order or decree and any other relevant documents here

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Have you ever been the subject of disciplinary action or had your membership revoked by a professional organization governing the practice of counseling, either secular or religious?

YesNo

Please explain

Have you been a defendant in a malpractice suit and either entered into a settlement agreement or paid court awarded damages?

YesNo

Please explain

The applicants for board certification as a Christian counselor must have completed a minimum of four graduate level courses in the principles and practice of Christian counseling. List these courses below and document the program in which they were completed.

	Course Title/Description	Institution	Date Taken
Course 1
Course 2
Course 3
Course 4
Course 5
Course 6
Course 7

List 3 people who have been either personal or professional advisors in the area in which you are seeking board certification and who will support your application for board certification. Provide each with a "letter of reference" form and ask them to return it to the board at 1635 OLD 41 Hwy Suite 112-222, Kennesaw, GA 30152.

	Name	Type of reference
Reference 1
Reference 2
Reference 3

Select any additional files that are relevant to the application here

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Upload your personal testimony (including your salvation experience) here

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Why would you like to pursue board certification as a Christian Counselor?

Please take a moment to review the Code of Ethics at this link prior to signing below.

I acknowledge that I may be required to furnish additional information promptly in order for this application to be processed. I attest that the information provided is true and accurate, to the best of my knowledge. I attest that I am a resident of the State of Georgia or that I intend to be within one year of the date of this application. I release from all harm the Georgia Board for Christian Counselors and authorize them to investigate and gather all information relevant to my application for board certification.

As a representative of Jesus Christ, I understand I am responsible to demonstrate a lifestyle consistent with His character and am expected to be men and women of high moral character whose sexual conduct is consistent with the standards of Scripture. This includes abstaining from any pattern of addiction and from homosexual, premarital, and extramarital sexual conduct.

I have read, understood, and agree to abide by the Code of Ethics as set forth by the Georgia Board for Christian Counselors.

Signature

Date

Click the button below to submit your application. You will then see a link to pay your application fee.

(All links are configured to open in a new tab but will not open in new tabs if you have a pop-up blocker turned on. You will want to turn off any pop-up blockers prior to clicking the submit button below.)

The application fee is $250 (non-refundable) for 2 years and includes the following:

· A Georgia Board for Christian Counselors magnetic lapel pin

· An ID badge holder and clip so you can display your certification

· Membership in the Georgia Christian Counselors Association: All members will be able to fill out their profile when their certification is processed completely.

· 10% discount on any courses or conferences put on or supported by either the Georgia Board for Christian Counselors or the Georgia Christian Counselors Association.

Note:

Part of the application process requires your references to fill out and submit the following form directly to The Georgia Board for Christian Counselors. Click here to download it.

Your application will not be processed until your payment has been processed.

Providing incorrect or partially incomplete applications will cause a delay until the problems are corrected.

Application for Board Certification

PERSONAL INFORMATION

OATH