Membership Application Associate Professional Counsellor (APC)

This is an entry level membership for insured practicing counsellors/psychotherapists and is the first step in becoming a Certified member. APC members will have 5 years to complete Certification requirements in order to maintain membership and insurance.

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.

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 Associate Professional Counsellor (APC) membership application to PACCP.

Title

Last Name

First Name

Sex

Age

Membership Applying for:

MAILING ADDRESS (for PACCP office use only)

Street/Box Number

City/Town

Province

Postal Code

Phone Number (Daytime)

Phone Number (Cell)

Email Address

How did you find out about PACCP?

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

Is this Institution accredited through a recognized accrediting authority as listed on PACCP"s website?

Have you completed a graduate level course in Counselling Professional Ethics (either as part of your program or post-grad)?

Have you completed the required 100 Supervised hours (internship/practicum) of client contact as part of your graduate program?

Other

Transcript

Attachment (Please attached a copy of your transcript)

Select File

VOCATIONAL INFORMATION

Years of Counselling Experience

Are you currently a practicing counsellor?

Other

How many hours a week do you work as counsellor?

Resume/CV

Attachment (Please attach a current resume/cv)

Select File

Name of Employer

Phone number of Employer

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)

Select File

LIABILITY INSURANCE

Would you like to enrol in PACCP"s group liability insurance policy?

Liability Insurance Application Forms

Attach the Liability Insurance application form

Select File

If not, do you have proof of liability insurance you've purchased on your own (minimum $5,000,000 liability)

Other

Proof of Insurance if purchased on your own

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

Select File

STATEMENT OF PROFESSIONAL ETHICS AND CONDUCT

Are you currently under investigation for alleged unethical/unprofessional conduct?

Other

Have you ever been disciplined by a professional association or regulatory body for unethical/unprofessional behaviour?

Other

Have you ever been charged with a criminal offence and/or convicted of an indictable offence?

Other

Have you ever been charged or convicted of any other offence (e.g., summary conviction or petty offence)?

Other

Has any claim/allegation been made against you in a civil suit or any other forum which clearly alleges unethical behaviour on your part including, but not limited to, the following: sexual intimacy with a client, a dual relationship with a client, violation of confidentiality, etc.?

Other

Have you ever been dismissed from employment or refused membership in a professional association ore registration in counselling or a related field, on the grounds of professional misconduct in Canada or elsewhere?

Other

Have you ever voluntarily given up privileges, registration, certification, or license to practice psychology, or agreed to restrict your practice in lieu of, or to avoid, formal action?

Other

CRIMINAL RECORD CHECKS

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

Criminal Check

Attachment (if providing electronic copies)

Select File

MEMBERSHIP AGREEMENT

I have read and understand the following and agree to abide by and adhere to them (Please check):

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

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$75.00 CAD

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

Total $0.00 CAD

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