Membership Application Associate Professional Counsellor (APC)

(Insured and Non Insured): A student enrolled in an accredited graduate degree in counselling, psychology, or other mental health discipline.

Application Document Checklist:

1. Current transcript from your graduate or doctoral degree showing current enrollment.

2. Resume/C.V.

3. Criminal/Vulnerable Persons Check (no more than 1 year old)

4. If wanting insurance, a completed liability insurance forms.

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 above 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 Student membership application to PACCP.

Title*

Last Name*

First Name*

Sex*

MaleFemale

Age*

Membership Applying for:*

Student Insured MembershipStudent Uninsured Membership

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.

What is the current graduate level degree you are pursuing?*

Degree or Specialization*

Institution*

Year of Expected Graduation*

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

YesNoUnsure

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

YesNo

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

YesNoOther

If you are applying for Student-Insured status, have you completed a minimum of a 2-year degree program with all required courses? For programs of study that are longer than 2 years, students must have completed a minimum of 90% of the required coursework in that program in order to qualify for insurance through PACCP.

YesNoOther

Transcript*

I have attached a transcript electronically below.I will be forwarding a transcript by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI have requested my school send PACCP a transcript directly to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email it to paccp@paccp.ca

Attachment (Please attached a copy of your transcript)

Select File

VOCATIONAL INFORMATION

Resume/CV*

I have attached an electronic copy of my resume/cv belowI will be forwarding this document by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email it to paccp@paccp.ca

Attachment (Please attach a current resume/cv)

Select File

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 Practicum Supervisor (must reflect the experience, competence and good practice of the applicant. This is for insured student applicants only.)

Attachment (if you have a written reference)

Select File

Reference #2 Professor*

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?*

YesNo

Liability Insurance Application Forms*

I have provided electronic copies of the liability insurance forms belowI will send the forms by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email the form to paccp@paccp.caI do not need insurance as uninsured student

Attach the Liability Insurance application form

Select File

STATEMENT OF PROFESSIONAL ETHICS AND CONDUCT

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

YesNoOther

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

YesNoOther

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

YesNoOther

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

YesNoOther

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.?*

YesNoOther

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?*

YesNoOther

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?*

YesNoOther

CRIMINAL RECORD CHECKS

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

Criminal Check*

I have provided a copy of my criminal check, including Vulnerable Persons search, in electronic format belowI will send this document by mail to PACCP, c/o National Administrator, 191 Vines Creek Drive, Greer, SC 29651 USAI will email this document to paccp@paccp.ca

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):*

PACCP Statement of BeliefsPACCP Principles of PracticePACCP Code of EthicsAll other regulations and policies for PACCP members

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*

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$50.00CAD

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

Total $0.00CAD

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Student Membership