When we receive your application which of the following would you like?
____ I would like to receive a telephone interview –or-
____ I prefer my Application be directly submitted to the AACT Certification
Review Board.
How did you hear about us?
a. ____ Internet search. Search engine? ___ Google ___ Yahoo ____ Other
b. ____ Referral
c. ____ Other _____________________
1. Full
Name: (Last)__________________ (First) _____________ (Middle)_____
2. Residence
Address: (No./St.) ___________________ (City) __________ (State) ______
(Zip Code) ______________ (Country) _______________________
3. Telephone:
____________________ Work: __________________
Email:
___________________________
4. City
of birth _______________ Country of birth __________________
5. Date of birth __________________Social Security #_______________
Sex: ___ Male ___ Female
6. Spouse’s
Name (If married) _____________Social Security # ___________
Number
of Children ____
7. If accepted as a Life Coach in the AACT, will you conduct yourself according to our statement of ethics?
(See ethics
statement below) 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
I am looking to use Coaching ____ Internally (inside my organization) ____
Externally in a practice ____ In other areas of ministry ________________________
8. Please
list the complete name and address of each educational institution you have attended. 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. 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. Do
you feel that your skills in counseling can be used to be successful as a Christian Life Coach? Please explain:
13. Are you an ordained minister? Mark one: ___ Yes ___ No (If yes, please
include a copy of your certificate
14. Why
have you chosen to apply for certification / license as a Life Coach with the AACT?
15. CHARACTER
REFERENCES: Please list the names, addresses, and phone numbers of Two character references who have known you for MORE THAN
3 YEARS. Special Note: Persons recommending CAN NOT be RELATED to each other or the applicant, either by birth or marriage.
Place your answer on an additional page and label as #15.
16. 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)
17. Are
you a full-time counselor? ____ Yes ____ No ( If No, what is your full-time profession?
18. 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.
19. Please
list your experience in People Development / Workplace Coaching (including number of years):
20. Are you looking to specialize in a specific
niche coaching area?
____ 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
____________________________________ ADD PHOTO HERE
DATE
________________________________________________________
APPLICANTS SIGNATURE
I AM APPLYING
FOR:
Life Experience,
Special Training and Bachelor’s level
_____ Certified Practitioner Life Coach (CCLC)
_____ Certified Pastoral Life Coach (CPPC)
Master’s and Doctoral Level
_____ Certified Master Life Coach (CMLC)
____ Licensed Master Life Coach (LMLC)
____ Licensed Pastoral Life Coach (LPLC)
ALL Certified Life Coach Levels: $159.00
All Licensed
Life Coach levels: $169.00
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.
SIGNATURE _____________________________________ DATE _________________________
Signature here does not mean that you agree but that you understand the statement.
If you do disagree please explain on another page. If you disagree you may still be certified by the AACT.
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.
SIGNATURE ______________________________________________________ DATE _____________________________
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.
(C). Please attach a a letter or official document
from a legal entity in EVERY state you have lived and worked since adulthood, concerning whether or not you have a criminal
record or are currently in litigation. We are specifically inquiring about child abuse convictions. You may use our
attached form and we will run the check for you.
