Clinical Pastoral Care Program Application

Clinical Pastoral Care Program Application

Center for Education Humanist Studies Program
Application Overview
You are required to complete an admissions interview with an ACPE Certified Educator, or a person approved by the program to which you are applying, or at the program to which you are applying. Contact the program to check on their policy regarding admissions interviews.

CPE Programs often require an application fee. Please check this requirement in advance of submitting this application. If you are interviewing at a program other than the one to which you are applying, you may be required to pay an interview fee, usually due at the time of the interview.

If you are an international applicant, you will ahve to obtain appropriate documentation from U.S. immigration, which usually implies a visa and a US Social Security Number. Therefore, international applicats should have such documentatio approved at least six (6) months in prior to start of the program to which they are applying. If offered employement, can you submit verification of your leagal right to work in the U.S.? Yes No

An applicant with prior CPE should attach all previous self and educator evaluations and your sinature below indicates you give permission for your previous CPE programs to release your evaluations for purposes of this application process.

Retain your own copy of this completed application and bring with you to any interview for CPE.

Please upload you current resume
Current Resume

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Personal History & Experience
Please respond to each of the following items. Upload typed responses with link below.

1) A reasonably full account of your life. Include, for example, significant and important persons and events, especially as they have impacted, or continue to impact, your personal growth and development. Describe your family of origin, current family relationships, and important and supportive social relationships.

2) A description of your spiritual growth and development. Include, for example, the Spiritual/Values-Based Orienting System into which you were born and describe and explain any subsequent, personal conversions, your call to spiritual care, religious or spiritual experiences, and signficant persons and events that have impacted, or continue to impact, your sprititual growth and development.

3) A desciption of your work (vocational) history. Include a chronological list of jobs/positions/dates of employment and a brief statement about your current employment and work relationships.

4) An account of "helping incident" in which you were the person who prvided the help. Include the nature and extent of the request, your assessment of the issue(s), problem(s), situation(s). Describe how you came to be involved and what you did. Give a brief, evaluative commentary on what you did and how you bleieve you were able to help. If you have had prior and recent CPE, please attach a copy of a recent verbatim as your 'helping incident' and add to the verbatim your own notes on how and what you learned from sharing this verbatim with your educator and/or peers. If you have had CPE, but it was more than two years ago, include a recent account of helping incident, written up in a verbatim format. If possible, include feedback from current spiritual care colleagues and/or administrative supervisor.

5) Your impressions of Clinical Pastoral Education. Indicate, for example, what you believe or imagine CPE to be. Indicate if CPE is being required of you. Inicate any learning goals or issues of which you are aware and would like to address in CPE. Finally, indicate how CPE may be able to help you meet needs generated by your spiritual practice or call to leadership in a theological, spiritual, or values-based system. If you have had prior CPE, please indicate the most significant learning experience you had during CPE. State how you have continued to use the clinical method since your previous experience. Indicate strengths and weaknesses that you have as the relate to your spiritual care practice and your identity as a professional person. Indicate any personal and/or professional learning goals and issues that you have at this time and how you believe that CPE will help you to attain or address these learning goals and issues.
Personal History & Experience

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Application for CPE - Program Selection
Application term
Program type
Preferred program/site
*Please note that residency programs usually require an in-person interview in their admissions process.
Earliest date you can begin

MonthDayYear
Date
Application for CPE - Directory Information
U.S. Citizen
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do You Have a Different Mailing Address?
Spiritual/Values-Based Orienting System
Denomination/Endorsing Body/Community of Affirmation (if applicable)
Name of Local Community
College Degree/Date
Graduate School Degree(s)/Date(s)
Prior CPE
Academic Reference
Name/Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Spiritual/Values-Based Orienting System Reference (name/title)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Personal Reference
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Admissions Interviewer
Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I certify that all information in this application is factually true, complete, and honestly presented. I understand that I may be subject to disciplinary action, including admission revocation or program expulsion, should the information I've certified be false. I hereby give permission to the ACPE program to which I am applying to access my CPE evaluations and contact previous educators about matters pertaining to this current application, and I consent for those contacted to provide the information sought. I verify that if sending in this application electronically it constitutes my electronic signature.
Applicant Signature
Signature of applicant
Application Date

MonthDayYear
Date
Should be Empty:

Clinical Pastoral Care Program Application

Application Overview

Personal History & Experience

Application for CPE - Program Selection

Application for CPE - Directory Information

Academic Reference

Personal Reference

Admissions Interviewer

Applicant Signature