Fillable Canadian Certified Counsellor (CCC) Reference Form

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Canadian Certified Counsellor (CCC) Reference Form

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

  • 1 signature
  • 23 check-boxes
  • 104 other fields

Country of origin: CANADA
File type: PDF

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Canadian Certified Counsellor (CCC) Reference Form
CCPA recommends that Referees complete this form and submit it directly to CCPA. Once a reference is received by CCPA, it
cannot be redacted or withdrawn. Please note that references can be accessed by applicants with the referee's consent or
through the Privacy Act and Personal Information Protection and Electronic Documents Act.
References must be provided by graduate-level counsellors, supervisors or counsellor educators who can speak to the
applicant's counselling competencies within the last ten years. The referee must be in a non-compliant relationship with the
applicant. All applicants must provide two reference forms with their application. PATHWAY TWO applicants must provide one
reference from a clinical supervisor who has engaged in formal supervisory activities according to CCC criteria and can speak to
the applicant's counselling competencies.
INCOMPLETE FORMS WILL NOT BE PROCESSED
CCPA_CCCREF_03_2021
1. Applicant Information
Name:
*First name: *Last name:
Other Legal Names:
Address:
*Number and street:
*City, Province, Postal code:
Email:
Telephone:
(home): (cell):
(work): (fax):
*Email:
2. Referee Information
Referee
Name:
*First name: *Last name:
Employer
info:
*Employer:
*Position Title:
*Telephone:*Email:
Education:
*Degree(s):
*Degree Specialization(s):
*During what time frame were you familiar with the applicant's counselling skills? (mm/yy - mm/yy)
To
*List your professional memberships / designations at the time that you worked with the applicant below
(please include the full name of the association or college, no acronyms):
3. Professional Relationship with Applicant
primary clinical practicum supervisor
university professor (practicum)
employer
clinical supervisor
supervisee (supervised by the applicant)
colleague
other (please explain):
*Please specify location where professional relationship took place below:
In what capacity did you know the applicant? Please check all that apply.
university professor (other courses)
*Is there any reason that you should not be considered an appropriate reference? (Please consider any
dual relationship, role conflict, overlapping roles, personal relationship, conflict of interest, supervisee,
lack of knowledge of applicant's clinical work as a counsellor, outdated knowledge of applicant skills,
etc).
No Yes
4. Supervision (only individuals listed as supervisors in Section 3 must complete this Section)
Other (please specify below):
Class meetings
Co-counselling / co-facilitating
Case consultation
Taped sessions
Direct observation
What types of supervision did you provide to the applicant (check all that apply):
Did you have 4 years of post-graduate counselling experience when you supervised the applicant?
No Yes N/A
Please indicate how often supervision with the applicant took place (check the box below that applies):
OccasionallyAs neededWeekly Other:
*What was the total hours of supervision provided to the applicant? (numeric values only):
5. Evaluation of Professional Counselling Competencies (based on the CCPA Code and Standards,
individual, couple/family or group counselling competencies must be evaluated)
High Average Low Cannot Evaluate
Individual counselling skills *
Couples or family counselling skills *
Group counselling skills *
Ability to establish and maintain an effective
working relationship with client(s)
Ability to work towards change
Ability to manage closure and ending of therapy
Shows sensitivity to diversity
Personal integrity
Consulting skills
Ability to relate to co-workers
Ability to be objective on the job
Supervisory abilities
Ability to keep material confidential
Ability to follow CCPA Code of Ethics
High Average Low Cannot Evaluate
Sense of responsibility
Recognition of own limits
Concern for welfare of clients
6. Recommendation (REQUIRED)
Additional Comments (regarding the applicant's competence, awareness, ability to follow the CCPA
Code of Ethics, etc):
*I recommend this applicant for certification as a Canadian Certified Counsellor:
YesNo
ATTESTATION:
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 you are 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 you are aware of will be disclosed to the Registrar)?
*If a digital signature is provided by the reference, the form must be sent to CCPA directly from the
individual who has provided the digital signature by email.
Yes
No
No
Yes
*If yes, please describe
:
*If yes, please
describe:
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.
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
*Referee signature:
*Date:
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Canadian Certified Counsellor (CCC) Reference Form

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Completed 3 May 2022

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