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:
[ ] (Certification)
Biblical/Christian Domestic
Violence Specialist $139.00
[ ] (Certification)
Christian Domestic Violence
Professional I $159.00
[ ] (License)
Christian Domestic Violence
Professional II $159.00
[ ] (License)
Domestic Violence Christian
Advocate $169.00
[ ] (License)
Domestic Violence Christian
Advocate Diplomate $189.00
Amount
Enclosed $ ___________________
Please
mail application with appropriate fee to:
AACT
P.O. Box 3634
Brookhaven, MS 39603