APPLICATION FOR CERTIFICATION AS A

CERTIFIED DOMESTIC VIOLENCE SPECIALIST

AND MEMBERSHIP IN THE

AMERICAN ASSOCIATION OF CHRISTIAN THERAPISTS

Use additional sheets of paper if necessary

1. Full Name: (Last)___________________(First) ___________________ (M.I)_______

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

2a. Post Office Box/Drawer: ______________________________________________

(City) ____________________(State) _______________ (Zip Code) _____________

(Country) ____________________________________________________________

3. Telephone:Home (___) _________________ Work (___) ____________________

Email Address _________________________  Web site: _______________________

4. Place of birth (City)__________________________ (State) __________________

Country of birth ________________________________________________________

5. Date of birth ____________  Age ____ Sex: ____ Male ____ Female

6. Spouse’s Name (If married)____________________________________________

Names and ages of Children:          ________________________________________

                                                __________________________________________________

                                                __________________________________________________

                                                __________________________________________________

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

(See ethics statement): ___ YES or ___ NO

Do you understand that any unethical practices on your behalf may cause you to lose your

membership in the AACT?  ___ YES ___ NO

8. Educational Data: YOU MUST PROVIDE THE COMPLETE NAME AND ADDRESS OF EACH EDUCATIONAL INSTITUTION YOU HAVE ATTENDED, USING A SEPARATE SHEET.

a.) List all Colleges, Schools, Institutes of Higher Learning, 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, continuing educational courses, 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? 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? ___ 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 (Work) ( __ ) _______________ (Home) (___) _________________________

Name ________________________________________________________________

Address _________________________ City _____________________ State ______

Zip _______________ Country ___________________________________________

Phone (Work) ( __ ) _______________ (Home) (___) ________________________

Name ________________________________________________________________

Address _________________________ City _____________________ State ______

Zip _______________ Country ___________________________________________

Phone (Work) ( __ ) _______________ (Home) (___) _________________________

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

misconduct? ____ YES ____ NO (If yes, 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? _____ Yes   _____ No

 Is your license still in effect?

If so, please provide license number, date of issue, and state in which license was issued.

If your license is not in effect, please state why.

Have you ever had a state license of any kind suspended, or revoked for any reason?

Are you currently certified or licensed through:

____ Your state

____ A National Organization

____ Religious organization.

If currently certified or licensed, please send a copy of certification and license along with this application.

I AM APPLYING FOR CERTIFICATION OR LICENSE AS: