3. Elective Courses (continued)
4.
5.
6.
4. Supporting Documentation: applicants must provide
CCC Practicum Form(s). One form per practicum placement.
CCC Work Experience Form(s). One form per employer/workplace. Letter(s) from employers may
also be a suitable alternative if they describe the nature of work and number of hours of employment.
A copy of your transcript and course descriptions must be submitted with your application; please see
the corresponding section on the Certification Guide. In addition, please identify which additional
documentation you wish to provide for evaluation by the Registrar.
TWO CCC Reference Forms (optional): completed, signed, and submitted by clinical references.
Note: If you are a Pathway 2 applicant, one reference must be from a clinical supervisor.
Resume / CV
Other (please describe):
6. Attestation: Please read carefully for important information regarding your application
I certify that the information provided in this application is accurate and complete to the best of my
knowledge and belief. I understand that the outcome of my application depends upon my demonstration of
how my application satisfies the required criteria, including presenting relevant coursework in Section 3 for
consideration by the Registrar. I will practice in accordance with CCPA's Code of Ethics. I have included a
valid criminal records check with vulnerable sector screening conducted within the last 12 months or will
submit one to CCPA shortly. I understand that any certification granted to me by the Canadian Counselling
and Psychotherapy Association does not in and of itself specify licensure to practice counselling for a fee,
monetary or otherwise. If I am granted certification by CCPA and practice counselling as a private
practitioner, I do so at my own risk. I hereby release CCPA from any and all liability and/or claim that may
arise from any decisions to practice privately as a Canadian Certified Counsellor. For research and
statistical purposes only, data resulting from my participation in this process may be used in an
unidentifiable manner. I understand that all material becomes the property of CCPA upon receipt and that
originals will not be returned to me, with the exception of the Criminal Records Check (if requested by the
applicant).
*Applicant signature:
*Date:
Credit Card # (Accepted methods:VISA, MASTERCARD, AMERICAN EXPRESS)
Expiry Date (MM/YY)
CVD
Card Holder's Name
*Signature:
*Date:
The total cost for this application is $40.00. Payment can be provided by cheque, money order, credit card
and Visa Debit.
Please send the form by Mail/Fax/Email to:
Canadian Counselling and Psychotherapy Association
202 - 245 Menten Place, Ottawa, ON, K2H 9E8
Fax: 613-237-9786 | E-Mail:
certification@ccpa-accp.ca
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