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 4 pages long and contains:

  • 3 signatures
  • 31 check-boxes
  • 67 other fields

Country of origin: CANADA
File type: PDF

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Canadian Certified Counsellor (CCC)
PATHWAY ONE: Practicum Form
CCPA recommends that the co-signer submit the form directly to head office. Once the form has been received by CCPA, it cannot be modified
or withdrawn. Please note that applicants can access the form with the consent of the co-signer or under the Personal Information Protection
and Electronic Documents Act.This form is for applicants following PATHWAY ONE. Please submit one form per practicum placement.
INCOMPLETE FORMS WILL NOT BE PROCESSED
CCPA_CCCPRAC_03_2021
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 primary clinical practicum supervisor who assumes primary responsibility for the
student's work. Supervisors must have engaged in formal supervisory activities and meet the qualification
requirements. All other supervisors must be listed in Section 4.
3. Primary Clinical Supervisor Information
Primary Clinical 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 (no acronyms):
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
How did you provide supervision (check all that apply):
Telephone
In-person Video Chat (Doxy, Zoom, Skype, etc.)
Asynchronous means (email, text, other manner that isn't live)
Other (please specify below):
Class meetings
Case consultation
How many hours per week of supervision did you provide? (numeric values only):
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:
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.
5.B. Hours of Practicum
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.).
*Intake:
Counselling Sessions:
*Assessments:
Other Activities (please describe):
*Please note intake, assessment, psychoeducation and asynchronous cannot
exceed 25% of total counselling hours.
*Psychoeducation:
Direct client counselling hours with individuals, couples and families
Time spent working directly with clients providing therapy.
Group Therapy:
Group Psychoeducation:
Manualized group sessions:
Additional group counselling hours:
Time spent working with groups. These hours are in addition to the hours listed above.
Total number of hours:
Please indicate how many total hours the applicant spent providing direct client counselling, group
counselling, and overall time spent at your practicum placement in the column to the right. The Registrar
evaluating your file also needs to know, for each of these three types of services, the breakdown of the
overall activities under each of the headings. Please also check off all activities in which you engaged at
your practicum placement, and indicate in the column on the right approximately what percentage of time
you spent engaging in each activity (ex. if your direct client counselling hours were entirely spent providing
counselling session, please indicate 100% in the column on the right).
Describe the nature of the counselling services provided and the theoretical interventions you used:
How did the applicant provide the counselling services? Please check each type of service delivery
methods used during the practicum placement, and beside each one specify approximately what
percentage of your sessions were delivered using that platform. (ex. if you did all of your sessions in-
person, check off in-person and indicate 100% beside it, but if you did half in-person and half video chat
then you would check off those two types and indicate 50% beside each one).
Telephone
In-person Video Chat (Doxy, Zoom, Skype, etc.)
Asynchronous means (email, text, other manner that isn't live)
Other (please specify below):
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)
And either:
Practicum professor's name and title (printed):
Signature:
Date:
Practicum supervisor's name and title (printed):
OR
Date:
Applicant's Signature:
7. Attestation (REQUIRED)
ATTESTATION (please check each box below to indicate your agreement):
Do you have any concerns about the applicant's fitness to practice, including but not limited to concerns
about their ethical and competent practices? Any concerns that I am aware of will be disclosed to the
Registrar.
Are you aware of any concerns about the applicant's fitness to practice raised by other educators, clinical
supervisors, administrative supervisors, clients, or other individuals involved in the applicant's practicum
training? Any concerns that I am aware of will be disclosed to the Registrar.
The applicant can complete the form and sign. This form must be verified with a signature from either an
primary clinical 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 practicum supervisor, the form must
be sent to CCPA directly from the individual who has provided the digital signature by email.
Signature:
Date:
I confirm that the student successfully passed the above stated evaluation.
I attest to the accuracy of the information on this form. 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 this form.
I confirm that as part of the practicum course requirements, a formal evaluation of the student's clinical
competencies was completed by either the practicum course professor and /or clinical supervisor.
No Yes
* If yes, please describe:
No Yes
*If yes, please describe:
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
6. COVID-19
Did COVID-19 negatively impact your ability to accrue direct client contact hours?
No Yes
(please specify):
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Canadian Certified Counsellor (CCC) PATHWAY ONE: Practicum Form

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Completed 3 May 2022

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