Student to Associate
Transition Request
Member Name
Email
example@example.com
Date of Graduation
Member Number
*
Attachment (Please attach a copy of your final transcript)
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Have you completed the required supervised internship (client contact hours) of 100 hours?
*
Yes
No
Other
Name of Supervisor
Phone Number of Supervisor
Attach a letter of reference from your supervisor stating your completion, what role he/she played in the supervision, what ratio of supervision you had, and reference comments.
Attachment (Letter from Supervisor)
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Have you completed the required graduate level Counselling Ethics course?
*
Yes
No
Other
Are you currently a practicing counsellor?
*
Yes
No
Other
Will you be purchasing liability insurance through PACCP or do you already have insurance through our policy?
*
Yes
No
Other
Attachment (Please attach a copy of your liability insurance application form, if applicable...OR, if you do not need liability insurance, please attach a copy of your proof of insurance)
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of
*
I have read, understand, and will adhere to the Statement of Beliefs.
I affirm that the information provided in this application is accurate and true.
I agree to abide by the objectives, Code of Ethics, disciplinary code and regulations of the Professional Association of Christian Counsellors and Psychotherapists
I give my permission for an authorized representative of PACCP to contact my supervisor for verification purposes.
Name of Applicant
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Further Comments:
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Should be Empty: