Use other sheets if necessary

1. Full Name: (Last)____________________________________________________

(First) ____________________________________ (Middle)___________________

2. Residence Address: (No./St.)

____________________________________________________________________

(City) _______________________________________________________________

(State) ______________________________________________________________

(Zip Code) ___________________________________________________________

(Country) ____________________________________________________________
3. Telephone:Home (_____) ______________________________________________
Work (_____) ________________________________________________________

Email Address ________________________________________________________

4. City of birth ________________________________________________________
Country of birth _______________________________________________________

Social Security Number ________________________________________________

5. Date of birth ________________________________________________________
Age _____________________________________ Sex: ______ Male ______ Female

6. Spouses Name (If married)_____________________________________________

Spouses Social Security Number _________________________________________ 

Number of Children __________

7. If accepted as a member if AACT, will you conduct yourself according to our statement of ethics?
(See ethics statement)

MARK ONE: ___ YES or ___ NO

Do you understand that any unethical practices on your behalf
may cause you to lose your membership in the AACT?

MARK ONE: ___ YES ___ NO

8. Educational Data: YOU MUST LIST THE COMPLETE NAME AND ADDRESS OF EACH EDUCATIONAL INSTITUTION YOU HAVE ATTENDED

a.) List all schools, Theological Seminaries, and Universities completed with degrees earned (if any).
ENCLOSE COPIES OF ALL DIPLOMAS AND TRANSCRIPTS
NOTE: Attach your information on a separate sheet of paper and identify list as the answer to #8.

b.) List all seminars, workshops, etc. you have attended or completed, and enclose a copy of any certificate you possess (Use an additional sheet if necessary and attach as answers to #8, part b).

9. List your experience in the counseling field. Include the number of years and where you have gained your experience (Use an additional sheet to answer this question and list as answer to #9).

10. When were you born again as a Christian? Please explain

11. How long have you been involved in the field of Christian counseling? Please explain:

12. Have you read the enclosed AACT doctrinal statement (on back)? Do you ___ agree or ___ disagree? (If you disagree, explain why. Use Additional attached sheet if necessary to answer #12)

Do you have another ministry besides counseling? Please explain

14. Are you an ordained minister?

Mark one: ___ Yes ___ No
(If yes, please include a copy of your certificate. Also list the full name and address of your credentialing organization, along with the organizations phone number)

15. Why have you chosen to apply for membership in AACT?

16. CHARACTER REFERENCES: Please list the names, addresses, and phone numbers of Two character references who have known you for MORE THAN 5 YEARS. Print two (2) copies of the Reference form and give to the two persons listed here.

Name _______________________________________________________________
Address _____________________________________________________________
City __________________________________________________ State _________

Zip _______________ Country __________________________________________

Phone ( ____ ) ________________________________________________________


Name _______________________________________________________________
Address _____________________________________________________________
City __________________________________________________ State _________

Zip _______________ Country __________________________________________

Phone ( ____ ) ________________________________________________________

17. Have you ever been dismissed from a position (secular or clerical) as a result of sexual misconduct?

____ YES ____ NO (If yet, explain on a separate sheet of paper, in detail)

18. Are you a full-time counselor? ____ Yes ____ No
( If No, what is your full-time profession?

19.  Have you ever held state licensing as a physician, psychologist, counselor, or as a therapist of any kind?

I heard about the AACT through
____ A friend ____ Christian Publication ____ Internet ____ Other
(please specify) _____________________

Upon being accepted as a member in the AACT, you will receive the following benefits:

1. Attractive annual membership certificate 
2. Group Email with other Christian Counselors / Therapists  
3. Opportunity for continuing education
4. Skills Training Workshops & Seminars
5. Professional liability insurance for Certified Therapists, Counselors and students in Masters
and Doctors degree programs. (Available to USA members only)

NOTE: Please enclose your membership fee with this completed application.
(a). If for any reason your application for membership at a NON-CERTIFIED LEVEL is declined, you will be reimbursed.
(b). If your application for membership at a CERTIFIED LEVEL is declined, you will be personally contacted and asked to consider taking certain steps that will result in your being approved at the CERTIFIED LEVEL.

SEND PHOTO WITH YOUR APPLICATION… It will be placed on your ID Card.

____ YES, I have completed the application in detail
____ YES, I have enclosed my membership fee of $ __________ and have checked the appropriate line to
indicate the level at which I feel qualified.
____ YES, I declare all the above statements to be true

___________________________________________________________
DATE


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APPLICANTS SIGNATURE


AACT  Doctrinal Statement (Philosophy)

WE BELIEVE THAT. . .

The Bible is our sole guide for truth and is the inspired, infallible, authoritative Word of God.

Divine inspiration extends equally and fully to all parts of the writings in the original
manuscripts and are therefore without error.

All Scriptures were designed for practical instruction in our everyday living.

WE BELIEVE IN THE . . .

Deity of our Lord Christ and that all Scriptures center around Him. We believe in His virgin birth, sinless life, miracles, vicarious atonement on the cross, bodily resurrection, ascension to the right hand of the Father, and in His personal return in power and glory.

New birth of the believer, in the salvation of lost and sinful people through personal repentance, and in regeneration by the Holy Spirit.

Present ministry of the Holy Spirit by whose indwelling the believer is able to live a godly life.

Resurrection of both the saved and the lost: of them that are saved into the resurrection
of life, of them that are lost unto the resurrection of damnation.

Spiritual unity of believers in our Lord Jesus Christ, that are all united to the risen and ascended Son of God, and are members of the Church which is the Body, and bride of Christ, which began at Pentecost. Its members are constituted as such regardless of membership or non-membership in the organized churches of earth.


Statement of Ethics

As a member of the American Association of Christian Therapists, I PROMISE to conduct myself at all times in an ethical manner becoming to my title. I shall not be self-serving or monopolizing, or take undue advantage of any person I choose to counsel.

I PROMISE to strive for excellence in my counseling. Whenever possible, I will continue to advance my learning and improve my counseling skills through continuing education.

I PROMISE to be fair in all my practices and with those I seek to help. When any act or practice of mine has been challenged by a counselee or the AACT, I shall endeavor to respond and help to solve the problem in a timely manner.

I PROMISE to counsel only within the boundaries of my training and experience. I will not intentionally jeopardize the well-being of any counselee by using innovative approaches or various psychotherapies on him/her when I am not trained properly or qualified in a specific discipline or modality. I will take the responsibility to refer a counselee to another counselor if I feel unqualified to help him/her.

I PROMISE to remember with every approach in counseling I realize that ultimately I am responsible for helping the counselee find a solution for their problem.


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SIGNATURE

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DATE

Your signature here states that you have read the above and understand... not that you necessarily agree with us