Fillable Canadian Certified Counsellor (CCC) PATHWAY ONE: Practicum Form

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Canadian Certified Counsellor (CCC) PATHWAY ONE: Practicum Form

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The Canadian Certified Counsellor (CCC) PATHWAY ONE: Practicum Form form is 3 pages long and contains:

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  • 14 check-boxes
  • 60 other fields

Country of origin: CANADA
File type: PDF

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Canadian Certified Counsellor (CCC)
PATHWAY ONE: Practicum Form
This form may be accessed by applicants under the Freedom of Information Legislation.This form is for applicants following
PATHWAY ONE. Please submit one form per practicum location.
INCOMPLETE FORMS WILL NOT BE PROCESSED
CCPA_CCCPRAC_04_2019
1. Applicant Information
Name:
First name: Last name:
Other Legal Names:
Address:
Number and street:
City, Province, Postal code:
Email:
Email:
Telephone:
(home): (cell):
(work): (fax):
2. Practicum Course and Site Information
Course code and title:
Name of your practicum course professor:
Dates of Practicum (mm/yy) - (mm/yy):
Practicum Site Name:
Practicum Address:
This section refers to the on-site practicum supervisor who assumes primary responsibility for the student's
work. On-site supervisors must have engaged in formal supervisory activities and meet the qualification
requirements. All other supervisors must be listed in Section 4.
3. On-Site Supervisor Information
On-Site Supervisor Name:
Workplace and position title:
Email: Telephone:
Graduate degree(s): Specialization(s):
List your professional memberships / designations at the time you supervised the applicant:
Did you have at least 4 years of post-graduate counselling experience at the time that you entered into a
supervisory relationship with the student?
No Yes
Other (please specify below):
Co-counselling / co-facilitating
Taped sessions
Direct observation
What types of supervision did you provide to the applicant (check all that apply):
Is there any reason that you should not be considered an appropriate supervisor? (Please consider any
dual relationship, role conflict, overlapping roles, personal relationship, conflict of interest, lack of knowledge
of applicant's clinical work as a counsellor, outdated knowledge of applicant skills, etc).
No Yes
Class meetings
Case consultation
How many weekly hours of supervision did you provide? (numeric values only):
Applicants must indicate all additional supervisors who provided formal supervision under Section 4 below, if
applicable. Any additional supervisors who do not fit on this page should be identified to CCPA.
4.A. Additional Supervisors. Please list any and all formal supervisors, one per column.
Additional supervisor name:
Graduate degree(s) and specialization(s):
Professional memberships / designations at
the time supervision occurred:
Did the supervisor have at least 4 years of
post-graduate counselling experience before
they began supervising the applicant?
YesNo YesNo
What percentage of the student's direct client
counselling did they supervise?
Ex, 10% of their clinical cases.
4.B. Supervisor of Supervisor. Please list any individuals who supervised the supervision provided to the applicant.
Supervisor Name:
Workplace and position title:
Email: Telephone:
Graduate degree(s): Specialization(s):
List their professional memberships / designations when supervision occurred:
Did they have at least 4 years of post-graduate counselling experience when supervision occurred?
No
Yes
Individual who received supervision:
Briefly describe the client population (age, milieu, typical presenting problem, etc.):
5.A. Scope of Practice (please refer to the definition on CCPA's website)
Please summarize the amount of time (in the form of a percentage or number of weekly hours) the
applicant spent engaging in various activities during this placement.
*Intake:
Counselling Sessions:
Group Counselling:
*Assessments:
Case and file management:
Supervision:
Consultation:
Other Activities (please describe):
Signature:
Date:
And either:
Practicum professor's name and title (printed):
Signature:
Date:
On-site supervisor's name and title (printed):
OR
Date:
Applicant's Signature:
6. Attestation (REQUIRED)
ATTESTATION: I attest to the accuracy of this information. I am willing to answer additional questions
concerning this evaluation if CCPA deems it necessary. I understand and consent to be contacted in
follow-up to the provided information on the CCC Practicum Form.
The applicant can complete the form and sign. This form must be verified with a signature from either an
on-site supervisor or practicum professor who can attest to the accuracy of the information on this form.
*If a digital signature is provided by either the practicum professor or on-site supervisor, the form must be
sent to CCPA directly from the individual who has provided the digital signature by email.
Direct Counselling Hours Indirect Counselling Hours
5.B. Hours of Practicum
Direct client counselling hours with individuals, couples and families:
Time spent working directly with clients providing real-time therapy.
Additional group counselling hours:
Time spent working with groups. These hours are in addition to the hours listed above.
Total number of on-site hours:
These are the total amount of hours you were on-site. They include your direct client hours above,
group counselling hours above, and the amount of time you spent providing indirect services (note-
taking, report-writing, supervision, research, consultation, preparation, etc.).
Total number of hours:
Describe the nature of the counselling services provided and the theoretical interventions you used:
*Please note intake and assessment cannot
exceed 25% of total counselling hours.
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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Canadian Certified Counsellor (CCC) PATHWAY ONE: Practicum Form

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Completed 14 June 2021

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