Download - CPSP Certification Manual Certification Manual - v1 - 2016.pdfCollege of Pastoral Supervision and Psychotherapy 3 THE COVENANT OF THE COLLEGE OF PASTORAL SUPERVISION & PSYCHOTHERAPY

CPSPCertificationManual2016Edition

CertificationManual(v.1;2016)

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CollegeofPastoralSupervisionandPsychotherapy

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THECOVENANTOFTHECOLLEGEOFPASTORALSUPERVISION&PSYCHOTHERAPY

We,theCPSPmembersseeourselvesasspiritualpilgrimsseekingatrulycollegialprofessionalcommunity.Ourcallingandcommitmentsare,therefore,firstandlasttheological.Wecovenanttoaddressoneanotherandtobeaddressedbyoneanotherinaprofoundtheologicalsense.Wecommittobeingmutuallyresponsibletooneanotherforourprofessionalworkanddirection.

MattersthataretypicallydealtwithinothercertifyingbodiesbycentralizedgovernancewillbedealtwithprimarilyinChapters.Thus,weorganizeourselvesinsuchawaythatweeachparticipateinarelativelysmallgroupcalledaChapterconsistingofapproximatelyadozencolleagues.TeachingorcounselingprogramsdirectedbyCPSPDiplomatesaretheprimaryresponsibilityoftheChapter.

Wecommitourselvestoagalaxyofsharedvaluesthatareasdeeplyheldastheyaredifficulttocommunicate.“Recoveryofsoul”isametaphorthatpointstowardthesevalues.Weplaceapremiumonthesignificanceoftherelationshipsamongourselves.Wevaluepersonalauthorityandcreativity.Webelieveweshouldmakeaspaceforoneanotherandstandreadytomidwifeoneanotherinourrespectivespiritualjourneys.Becausewebelievethatlifeisbestlivedbygrace,webelieveitessentialtoguardagainstbecominginvasive,aggressive,orpredatorytowardeachother.Webelievethatpersonsarealwaysmoreimportantthaninstitutions,andeventheinstitutionofCPSPitselfmustbecarefullymonitoredlestittakeonanidolatrouscharacter.

Weintendtotravellight,toownnoproperty,toaccumulatenowealth,andtocreatenobureaucracy.Weareinvestedinofferingalivingexperiencethatreflectshumanlifeandfaithwithinamilieuofsupportiveandchallengingcommunityoffellowpilgrims.


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IMPORTANTREMINDER

TheCertificationManualisupdatedfrequentlyandpostedonCPSP.ORGaftereachupdate.Pleasecheckourwebsite,ifyouhaveprintedthisout,tomakesurethatyourversionisthelatestversionofthemanual.Yourfeedbackiswelcomed–pleaseshareyourthoughtsandsuggestionswithus.

[email protected]


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Introduction

Inanefforttoimprovethecertificationexperience,theCPSPCertificationCommitteehasworkedtomakechangestotheprocessthatwillhelptosupportourcertificationcandidatesandorganizethewayweshareinformation.

Themostsignificantchangeinthecertificationprocessisthestreamliningandmergeroftheformsthatweusedinthepast,theChapterRecommendationforCertificationformandtheCertificationFacesheet,intooneform.ThenewformsareonthewebsiteatCPSP.ORG,undertheCertificationMenu.

OurmostrecenteditionoftheStandardsincludesareviewprocessforallSupervisorsinTraining,TrainingSupervisorsinTraining,andTrainingSupervisors.Therevisedformsincludetherequiredmaterialsforthesecategories.NotethatSupervisorsinTrainingandTrainingSupervisorsinTrainingwill,inadditiontotherequirementsatthechapterlevel,berequiredtoconsultwiththeCertificationCommitteetodeterminereadinesstobegintraining.TheconsultationwiththeCertificationCommitteewilloccurviaZoomVideoConferencing.ThoseseekingtobecertifiedasaTrainingSupervisorwouldcompletethecertificationprocessincludingthereviewwithaCertificationReviewPanelatoneofitsscheduledreviews.

AlldocumentsandinteractionregardingcertificationarelocatedonthewebsiteatCPSP.org.Allcandidatesandchaptersareencouragedtoreviewtheseresourceswellinadvanceofacandidate'scertificationprocess.Itisthecandidate'sresponsibilitytoknowthestepsinvolvedintheirprocessanditisthechapter'sroletoassistthecandidatewithongoingconsultationregardingthecandidate'spreparationforcertification.

AcentralizedandsharedDropboxfolderwillstillbeutilizedinthecertificationprocess,andcandidatesshouldbeawarethattheirsupportingdocumentsshouldnowbesubmittedasonedocument,apdf,totheirfolder(similartothesubmittingofanacademicresearchpaper).Thisistohelpstreamlinethereviewprocessandtokeepthefilesmanageableforthereviewpanels.

InadditiontoonlinecertificationformsandthecentralizingoftheDropboxfolders,membersoftheCertificationCommitteehaverecentlycompletedthefirstCPSPCertificationManual,aresourcemanualforcandidates,conveners,andChapters.Thecommitteehasspentmanyhoursreviewingdocuments,forms,andarticlestoprovidethisfirstadditionofthemanual.

AsCPSPutilizesthisprocess,updatesourgovernancedocumentsandforms,wewillalsoupdatethemanual.Thisisaworkingdocument.Wehopeyoufindthenewmanualhelpfulandwewelcomeyourfeedback.

WarmRegards,

JonathanFreeman,Chair


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TheCertificationCommitteeMembers

JonathanFreeman,ChairCharlesHicks,Administrator

KristaArgiropolis,AdministrativeCoordinatorPattyBerron,Member

PartheniaCesar,MemberMichaelEselun,MemberAndrewHarriott,MemberSusanMcDougal,MemberPerryMiller,MemberRuthZollinger,Member


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TableofContents

THECOVENANTOFTHECOLLEGEOFPASTORALSUPERVISION&PSYCHOTHERAPY.....3

Introduction.................................................................................................................5

TheCertificationCommitteeMembers ........................................................................6

BecomingCertifiedbyCPSP:AStep-by-StepExplanationoftheCertificationProcess ..8BecomeamemberofCPSP.................................................................................................................................... 8ThestepsforbecomingamemberofCPSP:....................................................................................................8ThebenefitsofmembershipinCPSP:.................................................................................................................8

MeetingtheStandardsforCertificationwithCPSP.......................................................9Education,Training,andEndorsements ......................................................................................................... 9Education.......................................................................................................................................................................9AdmissiontoPastoralPsychotherapyTraining............................................................................................9Endorsements...............................................................................................................................................................9EvidenceofSubscriptiontoTheCovenantofCPSPandcommitmenttobegovernedbytheStandards.................................................................................................................................................................... 10

DocumentsandDocumentRequirements....................................................................................................10DocumentsRequiredforDiplomateCertification.....................................................................................11VideoFormat,QualityandStorageforDiplomateSupervisorCandidates ....................................11DocumentsRequiredforDiplomateinPastoralPsychotherapyCertification .............................12DocumentsRequiredforPastoralPsychotherapistCertification ......................................................13ChapterRecommendationforCertification................................................................14ChapterRequirements ..........................................................................................................................................14Reciprocity.................................................................................................................16

Grandfathering–HospiceandPalliativeCare.............................................................16

CompletingtheConsultationReportforCertification.................................................17

PreparingfortheReviewPanel..................................................................................19CertificationFees .....................................................................................................................................................19CertificationFees,asofSept.2016:................................................................................................................. 19

Dropbox-FileSharingandStorage.................................................................................................................21TheReviewPanel.......................................................................................................22AftertheReviewPanel..........................................................................................................................................22FrequentlyAskedQuestions ......................................................................................23

AppendixA–CPSPCertificationForms–ConsultationReports(Allcertifications)......24


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BecomingCertifiedbyCPSP:AStep-by-StepExplanationoftheCertificationProcess

BecomeamemberofCPSP

CPSP members organize themselves in such a way that each participates in a small group called a chapter consisting of six to twelve colleagues. The essential spirit of CPSP is to know others and to be known by others. Full accountability for both professional practice and personal conduct is assured. Members monitor the professional competency of all activities, provide consultation whenever needed, and assess certification and membership requirements.1

ThestepsforbecomingamemberofCPSP:

1. Join a CPSP Chapter. 2. Complete the New Member Data Form, on our website at CPSP.ORG.

a. Submit completed forms to the Administrative Coordinator, Krista Argiropolis ([email protected]).

b. Krista will confirm the new member is a member of the Chapter listed on the Data Form.

c. Forms submitted by the Chapter’s convener would be processed more quickly, as confirmation (the above step) will not be necessary.

3. Aninvoicewillbesenttothenewmember.a. Paymentsmaybesubmittedbymailoronline.Instructionsforboth

paymenttypesaredetailedontheinvoiced.i. InvoiceswillcomefromtheCPSPwebsiteandshow“Collegeof

PastoralSupervision…”asthesender.ii. Atthistime,wecannottakecreditcardpaymentsoverthephone.

b. Immediatelyuponpayment,thememberwillbelistedintheDirectoryonCPSP.ORG,andtheywillreceiveareceipt.

i. AnnualduesaredueJan.1.

ThebenefitsofmembershipinCPSP:

• Yourname,contactinformation,andcredentialsarelistedintheCPSPDirectory.• MembersreceiveaninvitationanddiscounttothePlenary,theannualmeetingof

CPSP.• NotificationsofpostingstoPastoralReport,theCPSPjournal,eventannouncements

andreminders,andinternalemailnotifications.• Accesstoourcareeropportunitypostings.• SubscriptionaccesstotheJournalofPastoralCareandCounseling,anonline

resource.

1TheStandardsoftheCollegeofPastoralSupervisionandPsychotherapy,Section1220,Adopted2014andRevisedMarch2016.


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MeetingtheStandardsforCertificationwithCPSP

Education,Training,andEndorsements

Clinical pastoral education/training was conceived as a method of learning pastoral practice in a clinical setting under supervision. The concept developed by Anton T. Boisen uses the case study method in theological inquiry – a study of “living human documents.”2

In order to seek certification in CPSP, candidates shall demonstrate the following:

410.1 Education consistent with the required educational level for the certification being sought.

410.2 Clinical training consistent with the required level of training for the certification being sought.

410.3 Endorsement from the candidate’s faith group for the ministry for which certification is sought, when such endorsement is a normal practice of the candidate’s faith group. [Rev. 031616]

410.4 Evidence of subscription to The Covenant of the College of Pastoral Supervision and Psychotherapy and commitment to be governed by The Standards (including The CPSP Code of Professional Ethics), in such form as the Governing Council may, from time to time, prescribe. [NEW 092115]

410.4.1 If not submitted in conjunction with initial certification, subscription is mandatory for renewal of all certifications.3

Education

Pleasenoteifyouarelookingforequivalenciesthesearetobesubmittedtothecertificationteampriortoyourcertificationreviewandchapterapproved4.

Candidatesmustrequestapprovalforequivalencyforthetrainingoreducationrequirementsforthecertificationsbeingsought5.

AdmissiontoPastoralPsychotherapyTraining

MasterofDivinity,orMastersorDoctoral(orequivalent)leveldegreeintheology,Counseling,orrelateddisciplinesfromanaccreditedcollege,university,orseminaryorequivalentcourseofstudyparticulartothecandidate’sfaithtradition.

Endorsements

Theverificationofyourcurrentfaithgroupministryservicethatwillendorsesyou.6

2Ibid,Section210.3Ibid,Section410.4Ibid,Section430.5Ibid,Section320.1.


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EvidenceofSubscriptiontoTheCovenantofCPSPandcommitmenttobegovernedbytheStandards

Thetermusedtodemonstratereferstoboththewrittenandthearticulationofyourprocessthatyoucanshowthroughyourexperienceofconsistentchapterlifeandtheconsultationofyourpeersashapingofyourclinicalcompetenceandawarenessatanadvancedlevel.Thiscanbemaintainedbythediligenceofattendingyourchapterwhenitisfunctioningonyourbehalfasacandidateforcertification.

DocumentsandDocumentRequirements

Alldocumentsshouldbeatcollegelevelstandards(e.g.doublespaced,numberedpages,titlepagebetweensections,atableofcontents,references,footnotes,bibliographies,etc.)Pleasenotethatpapersshouldbetitledcorrectlysothatthereaderjoinsyouintheyourjourneyasyouaredemonstratinginwriting.

• Theautobiographicalsketchisyourreviewyourlifetodayusingtheclinicalpastoralskillwhatdoyounowaboutyourmajorlifeevents.Whatinsightsandobservationsinformyourworkinchaplaincyandhowhaveyouintegratedthisunderstanding?

• YourTheoryandTheologyofPastoralCareandCounselingpapershouldemphasizeyourgrowthandunderstandingintheseareasbasedontheclinicalpastoraleducationand/ortrainingandtheclinicalprocess.Howyouunderstandanddemonstratethecompetencies,personally,professionallyandclinically?

• CaseStudiespaper:Thisisanopportunityforyoutodemonstrateyourgrowthandlearning.Therefore,yourfirstCaseStudycanreflectyourissuesandlearningatthebeginningofyourprocess.CaseStudyTwomayreflectyoursuccessorissuesyouarestillworkingwithwhiledemonstratingyourawarenessofyourprocessattheendoftheunit.CaseStudiesshouldberelativetotheappropriatetimeframeofcertification.

• FinalUnitEvaluation:Certificationrequiresthatyoursupervisorshouldmakeevaluationsavailabletoyou.

6Ibid,Section540.2.


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DocumentsRequiredforDiplomateCertification

ExcerptfromTheStandardsoftheCollegeofPastoralSupervisionandPsychotherapyonthedocumentsrequiredbycandidatesseekingDiplomatecertification:

540.1.1AcomprehensiveAutobiographicalsketch,nottoexceedtenpages,outliningthecandidate’sjourneyandinsightsgainedfromthepsychodynamicprocess.

540.12Acomprehensivetheorypaperofsufficientlengthtodemonstratetheintegrationofpersonal,professional,theoretical,theological,andclinicalcompetencyincompliancewithacademicwritingstandards.

540.1.3Exhibitsfromasingleunitofsupervisedtraining,asfollows:

Videorecordingofonecompletegroupsupervisorysessionwhereaclinicalcaseispresented.

TrainingSupervisorcandidateswillpresentavideorecordingofonecompletesupervisorysession.

Apaper,nottoexceedfivepages,istoaccompanythevideothatprovidesananalysisofthesessionandreflectsthecandidate’suseofselfandone’sintegrateduseoftheoryandtheologyintheirpractice.

Thesyllabusofthetrainingunitpresentedforreview.

Evaluationswrittenbythecandidateofalltraineeswhoparticipatedinthecandidate’ssupervisedunitandallevaluationswrittenbythetrainees.

Narrativeofonetrainee’sprogressivedevelopmentthroughtheunit,withcandidate’sassessmentoftheimpactofbothindividualandgroupsupervision.

Trainingsupervisor’sevaluationofcandidate’ssupervisedunit.

540.1.4Evidenceoffaithgroupendorsementifappropriate(¶410.3).

VideoFormat,QualityandStorageforDiplomateSupervisorCandidates

Videosmusthaveclearaudio,andvisualofbothtrainee’sandsupervisorshowingtheworkofthegroup,andtheinteractionoftheparticipants.

Werecommendvideostobeplacedonathumb-drive,DVD-R,orsomeothersecurewaytostoreandtransportthevideo.Videofilesshouldbea.MP4,.mov,or.dviformat.Thecandidateneedstoprovidealaptop,withsound,tofacilitateshowingthevideoatthereview.Thereviewpanelwillnotprovidealaptop,DVDplayerandTV,orothermedia,sothecandidateneedstobepreparedforthispartoftheirreview.


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DocumentsRequiredforDiplomateinPastoralPsychotherapyCertification

ExcerptfromTheStandardsoftheCollegeofPastoralSupervisionandPsychotherapyonthedocumentsrequiredbycandidatesseekingDiplomateinPastoralPsychotherapyCertification:CandidatesforcertificationasaDiplomateinPastoralPsychotherapymustsubmitsupportingmaterialsasrequiredbythechapter,whichincludesbutisnotlimitedtothefollowing:

640.1Acomprehensiveautobiographicalsketch,nottoexceedtenpages,outliningthecandidate’sownpilgrimage,includinghowhis/herpsychotherapeuticjourneyimpactsuponhis/herunderstandingandpracticeofpastoralpsychotherapysupervision.

640.2Acomprehensivetheorypaperdelineatinghis/hersupervisorytheory,incompliancewithacademicwritingstandards.

640.3Evidenceofcurrentstatelicensureorcertificatetosupervise,ORbeapprovedbyacognategrouptosuperviseinspecificmentalhealthdisciplines,ORreceivefifty(50)hourssupervisionofsupervision.

640.4Evidenceofhavingcompletedaminimumof30contacthoursofgraduate-levelcourseworkinclinicalsupervision.

640.5Evidenceofhavingprovidedatleast150hoursofpastoralcounselingsupervision.

640.6Exhibitsfromasingleunitofsupervisedtraining,asfollows:[NEW031616]

640.6.1Videorecordingsofonecompletegroupsupervisorysession.[RevisedandRenumbered031616](notrequiredforthiscertification)

640.6.2Thesyllabusoftheunitinpastoralpsychotherapytrainingsupervisedbythecandidate.

640.6.3Evaluationswrittenbythecandidateofalltraineeswhoparticipatedinthecandidate’ssupervisedpastoralpsychotherapyprogram.

640.6.4Narrativeofonetrainee’sprogressivedevelopmentthroughtheunit,withcandidate’sassessmentoftheimpactofbothindividual,groupsupervision.[NEW031616]

640.6.5Trainingsupervisor’sevaluationofcandidate’ssupervisedunit.

640.7Evidenceoffaithgroupendorsementifappropriate(¶410.3).


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DocumentsRequiredforPastoralPsychotherapistCertification

CandidatesforcertificationasaPastoralPsychotherapistmustsubmitsupportingmaterialsasrequiredbythechapter,whichincludesbutisnotlimitedtothefollowing:[Rev.031616]

840.1Acomprehensiveautobiographicalsketch,nottoexceedtenpages,outliningthecandidate’sownpilgrimage,includinghowhis/herpsychotherapeuticjourneyimpactsuponhis/herunderstandingandpracticeofpastoralpsychotherapy.

840.2Audioorvideorecordingsoftwocompletepsychotherapysessionsalongwiththecandidate’sbriefassessmentofeachsession.

840.3Acomprehensivetheorypaperofsufficientlengthtodemonstratetheintegrationofpersonal,professional,andclinicalcompetence,addressingtheoriesofpersonality,psychology,andtheology.

840.4Arecordingofaportionofapsychotherapysessionnotmorethan15minutesinlength(tobeplayedduringthecertificationreview).

840.5Finalevaluationsofthecandidate’strainingprocesswrittenbythecandidateandthetrainingsupervisor.

840.6Evidenceoffaithgroupendorsementifappropriate(¶410.3)[Rev.031616]


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ChapterRecommendationforCertificationAfterbecomingamemberofCPSPandpreparingforyourcertification,yournextstepwillbetomeetwithyourChaptertoreviewyourqualificationsforcertification.YourChapterrecommendsyouforcertification,andre-certificationiscompleted,attheChapter-level,annually7.

ChapterRequirements

ThecertificationcandidateneedstomeettheChapterrequirementstobegintheprocess,forexample,beingamember,ingoodstanding,forsixmonthstooneyear.

TheChaptershouldallowtimeforthecandidatetoreflectonthefeedbackgivenfromtheChapter.ThereforeaChaptershouldbeginthecertificationprocessnolaterthanthree-to-sixmonthspriortoacertificationreview.

ExcerptfromTheStandardsoftheCollegeofPastoralSupervisionandPsychotherapy:

440.ChapterCertificationConsultations

Thepurposeoftheconsultationistoestablishthatthecandidatehasachievedthecompetenciesexpectedforthelevelofcertificationforwhichapplying.

440.1Priortotheconsultation,thecandidateshallsubmittothechapterallwrittenandvideomaterialsrequiredbyCPSPStandardsforthelevelofcertificationsought.Thesematerialsshallreflectprofessional-levelcontent,form,andorganization.

440.1.1Thechaptermaydeclinetoconductthepre-certificationconsultationif,intheirjudgment,thecandidateisnotprepared.

440.2CandidatesseekingcertificationfirstmustbereviewedbytheirchaptertodeterminereadinesstomeetwiththeCertificationCommittee.

440.2.1Certifiedchapterswithnolessthanfourmemberscertifiedatthesamelevelasthecertificationsoughtbythecandidateshallconducttheinitialstageoftheconsultationreview(CriticalMass).

440.2.2Chapterswithfewerthanfourmemberscertifiedatthelevelsoughtbythecandidateshallproceedtoestablishaconsultationwithachaptercertifiedtoprovidetheconsultation.(¶1220.9).

440.3Theconsultationmayaddressanyissuescoveredinthecandidate’swrittenmaterialsandotherpersonalorprofessionalmattersthatarerelevanttothecandidate’sabilitytofunctionatthelevelforwhichheorsheseekscertification.

440.4Uponcompletionofthecommittee’sdeliberations,thecandidateshallbeimmediatelyinformedoftheirrecommendation.

7Ibid,Sections1200,1210.2,1230.2,1230.3.


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440.4.1CandidatesrecommendedtoproceedtothecertificationreviewprocesswillbereportedtotheCertificationCommittee.TheChapterConsultationReportshalladdress,amongotheritems,thechapter’sunderstandingofthecandidate’sstrengths,weaknesses,clinicalandprofessionalfunctioning,andshallincludethecandidate’swrittenmaterials.

440.4.2Ifthechapter’sconsultationcommitteedetermines,followingitsreview,thatthecandidateneedsfurtherprofessionalpreparationanddevelopment,thechapterwillcontinuetosupportandguidethecandidateinaddressingthedeficiency.

440.4.3Whenthechapterissatisfiedwiththecandidate’sprogressinremediatingalldeficiencies,thechaptermayinvitethecandidatetoresumetheconsultationprocessattheinitialstage(¶430.1).


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ReciprocityCandidates seeking certification by means of reciprocity, favorably recommended for certification by their Chapter, will take the following steps:

1. Complete and submit the Consultation Report form 2. Submit their document to Dropbox 3. Pay the initial certification fee, but not the review panel fee.

The Certification Committee will review the candidate’s document and form, and respond to approve the candidate for certification, or respond to recommend that the candidate sit for a review panel. Candidates, who are asked to sit for a review panel, will be asked to pay the review panel fee.

Grandfathering–HospiceandPalliativeCareCandidates seeking subspeciality certification for Clinical Fellow in Hospice and Palliative Care of Clinical Associate in Hospice and Palliative Care, should be currently certified as a Clinical Chaplain or Associate Clinical Chaplain by CPSP, respectively, and meet the criteria in the CPSP Standards, Section 1000,will take the following steps:

1. Complete and submit the Consultation Report form 2. Submit their document to Dropbox 3. Pay the initial certification fee, but not the review panel fee.


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CompletingtheConsultationReportforCertificationThecertificationsformsarenowavailableonline.Alistoftheforms,andthecorrespondingcertificationsareshownbelow.Thecurrentformstaketheplaceoftheformerfacesheets,andrecommendationformsthatweresubmittedbytheChapter,inthepast.

CERTIFICATIONFORM8 CERTIFICATE(S)

ConsultationReportforClinicians

BoardCertifiedClinicalChaplain;BoardCertifiedPastoralCounselor;BoardCertifiedAssociateClinicalChaplain;BoardCertifiedAssociateClinicalChaplain

ConsultationReportforDiplomatePsychotherapist

DiplomatePsychotherapist

ConsultationReportforDiplomateSupervisor

DiplomateSupervisorinClinicalPastoralEducation

TrainingSupervisor’sReportofRecommendationforCPSPDiplomateSupervisorCandidate9

DiplomateSupervisorinClinicalPastoralEducation

ConsultationReportforPastoralPsychotherapist

BoardCertifiedPastoralPsychotherapist

ConsultationReportforSITandTSProgram

Supervisor-in-TrainingorTrainingSupervisor10

ConsultationReportforHospiceandPalliativeCare

ClinicalFellowinHospiceandPalliativeCare

ClinicalAssociateinHospiceandPalliativeCare

ConsultationReportforClinicallyTrainedMinister

CertifiedClinicallyTrainedMinister

8SeeAppendix1,ConsultationReportForms,Samples.9WiththeexceptionofDiplomateSupervisorcandidates,onlyoneformisnowrequired.DiplomateSupervisorcandidateswillrequiretheTrainingSupervisor’sReportofRecommendationforCPSPDiplomateSupervisorCandidateform,aswellastheConsultationReportforDiplomateSupervisorform.10SitsforareviewpaneloftheCertificationCommittee;nofeeforthispanel.


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• ConsultationsReportswillbecompletedbytheentireChapterandsubmittedbytheChapter’sconvenertotheAdministrativeCoordinator.AllChaptermemberswillbecopiedontheemail.

• Incompleteformsorhandwrittenformswillnotbeaccepted.• CompletedformswillbeemailedtotheCPSPAdministrativeCoordinator,whowill

respondwithaninvoiceforthecandidatefortheircertificationfees,andalinkforthecandidatetouploadtheirsupportingdocumentstoaDropboxfolder(seefollowingsections,CertificationFeesandDropbox.)

• Candidateswillconfirmwhichupcomingreviewpaneltheyareplanningtositfor,withtheAdministrativeCoordinator.


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PreparingfortheReviewPanel

CertificationFees

OncetheCPSPCertificationFormhasbeenreceived,candidateswillreceivebyemailaninvoicefortheircertificationfees.Paymentsmaybemadeonlineorbymail,andinstructionsforbothpaymenttypesareincludedontheinvoice.Pleasenotethatthecertificationfeesaresubjecttochange,andthemostcurrentscheduleofduesandfeesispostedonCPSP.ORG.

CertificationFees,asofSept.2016:

Aninitialcertificationfee,non-refundable,of$100.00(USD)willbechargedforeachofthefollowingcertifications:

• BoardCertifiedClinicalChaplain• BoardCertifiedPastoralCounselor• BoardCertifiedPastoralPsychotherapist• BoardCertifiedAssociateClinicalChaplain• BoardCertifiedAssociatePastoralCounselor• ClinicalFellowinHospiceandPalliativeCare• ClinicalAssociateinHospiceandPalliativeCare• ClinicallyTrainedMinister• SupervisorinTraining11• TrainingSupervisor12

Aninitialcertificationfee,non-refundable,of$150.00(USD)willbechargedforeachofthefollowingcertifications:

• DiplomatePastoralPsychotherapist• DiplomateSupervisorofClinicalPastoralEducation

TheReviewPanelFee,non-refundable,$250.00(USD)willbechargedforthecertificationslistedabove,exceptfor:

• ClinicalFellowinHospiceandPalliativeCare• ClinicalAssociateinHospiceandPalliativeCare• ClinicallyTrainedMinister• Anycandidateseekingcertificationviareciprocity

PleasenotethatthefollowingcertificationswillsitforareviewwithapaneloftheCertificationCommittee,viavideo-teleconference(e.g.Zoom),andthereisnoreviewfeefortheirpanel:

• SupervisorinTraining• TrainingSupervisor

11Thisfeeisproposedforthe26Sept.2016meetingoftheGoverningCouncil,andispendingtheirapproval.12Seeabovenote–re:GoverningCouncilapprovalispending.


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TheReviewPanelFeewillbechargedeachtimeacandidatesitsbeforeareviewpanel.


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Dropbox-FileSharingandStorage

Dropboxisafreefilehostingservice,offeingsecurecloudstorage.OncetheCPSPCertificationFormhasbeenreceived,candidateswillreceivebyemailfromtheAdministrativeCoordinatorthatasharedDropboxfolderhasbeensetupforthemtouploadtheirsupportingdocuments.

IMPORTANT! Documents should be merged

into one document, a .pdf, for upload.StartyourownDropboxaccount(itisfree):

1. GotoDropbox.comandstartanaccount.It’sfree.(Youmaybeaskedtoaccepta“specialoffer”–ignoreit.)

a. Dropboxappsmaybeinstalledonsmartphonesortablets–visityourdevice’sapplicationstoreandsearch“Dropbox”.

2. CompletetheintroductiontoDropbox,whichispartofthesign-upprocess.3. Remember–don’tcreateafoldertosharewiththeAdministrativeCoordinator–

youwillbeinvitedtoshareafolder–waitfortheinvitation.

WhenyoureceiveaninvitationfromtheAdministrativeCoordinator,takethefollowingsteps:

1. Clicktheinvitationlinkthatyoureceived,andclickonViewFolder.2. SignintoyourDropboxaccount.3. Clickthenotificationicon(abell).4. ClickAddtoDropboxunderthesharedfolderyouwanttoaccess.

Howtouploadyourfilestothesharedfolder:

1. SignintoyourDropboxaccount.2. Clickonthesharedfolder.(Note:Your3. Openthefolderonyourcomputerwhereyourdocumentisstored,clickonthe

documenttohighlightit,anddragitintotheshardfolder.4. NotifytheAdministrativeCoordinatorthatthisstepiscomplete,sothatyourfolder

andfilesmaybesharedwiththeReviewPanel.

IMPORTANT! All documents and forms must be submitted sixty (60) days

before the review panel is scheduled to meet.


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TheReviewPanelReviewpanelsareheldthreetimesayear–thedaybeforethestartofeventssuchas:NCTS-East,NCTS-West,andthePlenary.AdditionaldatesforReviewPanelsmaybescheduled,asneeded.ReviewdatesarepostedonthewebsiteatCPSP.ORG,intheEventssection.

Atthispoint,candidatesandtheirChapterswillhavecompletedthefollowing:

1. MembershipCPSPChapter,ingoodstanding.2. FollowinganextensivereviewwiththeirChapter,thatChapter’srecommendation

forcertification,or,iftheChapterdoesnothavecriticalmass,recommendationfromaconsultingChapterforcertification.

3. SubmissionoftheConsultationReportformtotheAdministrativeCoordinator.4. Paymentofthecertificationfees.5. Submissionoftheirsupportingdocument(a.pdf)inaDropboxfolder,andnotifying

theAdministrativeCoordinatorthatthisiscomplete.6. Steps3,4,and5,above,completedwithin60daysbeforethereviewpanelis

scheduledtomeet.

Afterthe60-daydeadline,amemberoftheCertificationCommitteewillcontactthecandidatewiththelocationandtimeoftheirmeetingwiththeReviewPanel.

Candidatesshouldarrivebeforethescheduledreview,andbepreparedwithahard-copyoftheirsupportingdocumentsthatareinDropbox,acopyoftheirConsultationReport,and,forcandidatesseekingcertificationasaDiplomateSupervisor,theyshouldalsohavealaptop,portableDVDplayer,orothermeanstoplaytheirvideo,aswellastheirvideoonaDVDorthumb-drive.

Reviewsgenerallytakeatleastonehourtoninetyminutes.

Candidatessittingforareviewpanelthattakesplacebeforeanevent,suchasNCTS-East,NCTS-West,thePlenary,etc.,arenotrequiredtoregisterandstayfortheevent(theyarewelcometodoso,butnotrequired.)

Candidatesareresponsiblefortheiraccommodations,travel/groundtransportation,meals,etc.

AftertheReviewPanel

TheReviewPanelwillinformthecandidate,atthereview,iftheyarebeingrecommendedforcertification.

Certificatesareissuedattheannualmeeting,ThePlenary,usuallyinmid-March.IfacandidatecannotattendaPlenary,theircertificatemaybepickedupbysomeoneattendingtheevent,orthecertificatemaybeshippedtothemafterthePlenary.

Candidate’scertification(s)willbeaddedtotheirnameintheCPSPDirectory,atCPSP.ORG,aftertheannualmeeting.

Candidateswhoarenotapprovedforcertificationwillreceiveareport,includingrecommendations,within30-daysoftheirreview.


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FrequentlyAskedQuestions

DoIqualifyforcertificationwithCPSP?

ThatisagoodquestionforyoutodiscusswithyourChapter.Ifyou’reconsideringcertification,asktotalkaboutyourcandidacyattheirnextmeeting.

Howlongdoesittaketogetcertified?

Therearetoomanyvariablestoprovideananswertothatquestion.OnceyourChapterrecommendsyouforcertification,decidewhichreviewpanelyouplantositfor,andthedeadline(60dayspriortothatreviewpanel)foryourdocuments.Thatwillgiveyouanideaofthetimeyouhavetoworkwith,toprepare.

Anothergroupalreadycertifiedme–doesthatmeanIqualifyforreciprocity?

Reciprocityisgrantedonacase-by-casebasis.Youwillneedtosubmityourdocumentsandforms,andpaytheinitialcertificationfee(butnottheReviewPanelFee.)OncetheCertificationCommitteehasreviewedyourdocuments,theywillletyouknowifyouqualifyforcertificationviareciprocity.

Myfaithgroupdoesnotordainorendorse–canIbecertified?

IfyouarewithafaithgroupthatisnotlistedasanEndorsingBodyonourwebsiteoronethatdoesnotendorseaspartoftheirregularpractice,thenyouqualifyforcertification.

CanIhaveanextensiononthesixtydaystosubmitmydocumentstoDropbox?

No,becausewearealreadyplanningforthetravelarrangementsandscheduleforthereviewpanel,andthepanelmembershavestartedreviewingthecandidates’materials.

I’vesubmittedallofmydocumentstoDropbox.Canyoureviewthemandtellmeifmydocumentsareaccurateorcomplete?

WecanconfirmthatyourdocumentsareinDropbox,however,yourChaptershouldhavealreadycompletedacomprehensivereviewofyourformsanddocumentsbeforethispoint.Ifyoufeelyouneedanotherreviewofyourdocuments,pleasecheckwithyourChapter.


24

AppendixA–CPSPCertificationForms–ConsultationReports(Allcertifications)

College of Pastoral Supervision & Psychotherapy

Certification Consultation Report for Clinicians This form is to be completed and submitted by an appointed member of the Chapter serving as one of the consultants. If the chapter has determined that the candidate is not yet prepared for certification (and is therefore not prepared to meet the Review Panel) this report does not need to be submitted but may be used for the chapter’s consultative process with the candidate. Please save the completed form to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – Chapter Consultation Report Form” or “Hernandez – Chapter Consultation Report Form”. Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), and please keep a copy for your records.

Section 1. General Information’

1.1 Today’s Date:

1.2 Check Certification(s) the candidate is seeking:

Pastoral Counselor Clinical Chaplain Associate Pastoral Counselor Associate Clinical Chaplain

1.3 Candidate’s Name:

Please type it exactly as it should appear on the certificate

1.4 Candidate’s Chapter:

1.5 Candidate’s Email:

1.6 Convener’s Name:

1.7 Convener’s Email:

1.8 Date or event Candidate is seeking for Review Panel:

(If unknown, type “unknown”.) There are two training seminars in the East and one in the West. (NCTS-East, NCTS-West) Additional reviews may be scheduled in the west, and elsewhere if needed. The Review Panel informs the chapter convener within 30 days prior to the upcoming Governing Council meeting regarding the status of its recommendation.

Cert Form – Clinicians Page 2 of 1009/01/16

1.9 Does the Chapter have Critical Mass? Yes (skip 1.9) No (see 1.9) Critical Mass is four or more members holding the same certification that the candidate is seeking.

1.10 If No, what is the name of the Chapter working with the candidate?

1.11 Date of Consultation Meeting with Chapter:

1.12 Candidate has paid dues and is listed in the CPSP Directory? Yes No

1.13 Candidate is in good standing and attends Chapter meetings? Yes No

1.14 Candidate is Board Certified Clinical Chaplain or Pastoral Counselor with CPSP or other cognate group? Yes (see 1.14 and 1.15) No (skip 1.14 and 1.15)

1.15 If Candidate is certified with another cognate group(s), please list the name of the group(s)?

1.16 List certifications:

1.17 Ethical and CPSP Commitment Evidence of high ethical commitment, including absolute respect for the worth and rights of persons. Level of commitment to CPSP’s mission and Standards as a means to provide an exceptional CPE training program that represents CPSP well in the public domain. RESPONSE:


Section 2. Education and Training

2.1 Degree(s): Associate Bachelor Master (M.Div.) Doctorate

2.2 Dates(s) of graduation:

2.3 College or University, name and location:

2.4 Seminary or Graduate School, name and location:

2.5 Other degrees: Yes (see 2.6) No (skip 2.6)

2.6 If Yes, date of graduation, name of degree, area of study, name and location of college, university or seminary:

2.7 Training: Completion of CPE (four units or 1,600 hours required for BCCC/PC):

Yes No Completion of CPE (two units or 800 hours required for ABCCC/PC):

Yes No

CPE Center Name & Location Training Dates Supervisor’s Name


Section 3. Faith Group, Endorsement

3.1 What is your faith group?

3.2 Are you ordained? Yes No If Yes, name of ecclesiastical ordaining authority and contact information:

3.3 Are you endorsed? Yes No If Yes, name of ecclesiastical endorsing authority and contact information:

In religious bodies where ecclesiastical endorsement is required, please attach a copy of the endorsement letter to this application. A list of the Endorsing Bodies is on our website at cpsp.org, in the section for Certification.


Section 4. Standards

4.1 Does the candidate meet all other Standards for the certification requested? Yes No

4.2 Read and initial: I, the candidate, understand that this certification must be renewed annually through Chapter affiliation. If I allow this certification to lapse, I will not present myself publicly as a CPSP certified person. The CPSP Directory lists all certified and non-certified members of the College of Pastoral Supervision and Psychotherapy. Any persons representing themselves as CPSP certified and not listed in our directory are misrepresenting themselves.

Candidate’s Initials:


Section 5. Supporting Documents

5.1 Certification materials will be submitted as one file, a .pdf, for the review panel. Clinical Chaplain/Associate Clinical Chaplain (Section 740 of the CPSP Standards, approved 03/16/16):

740.1 A comprehensive autobiographical sketch. 740.2 Two case studies demonstrating recent clinical work. 740.3 A comprehensive theory paper of sufficient length to demonstrate the integration of personal, professional, and clinical competencies (¶ 730), addressing theory and theology of pastoral care and counseling. 740.4 Evidence of faith group endorsement if appropriate (¶ 410.3).

Pastoral Counselor/Associate Pastoral Counselor candidates must submit supporting materials as required by the Chapter, which includes but is not limited to the following:

940.1 Comprehensive autobiographical sketch. 940.2 Two case studies demonstrating recent clinical work. 940.3 Comprehensive theory paper of sufficient length to demonstrate the integration of personal, professional, and clinical competence, addressing theory and theology of pastoral care and counseling. 940.4 Evidence of faith group endorsement, if appropriate (¶ 410.3). [Rev. 031616]


Section 6. Chapter’s Report

The Chapter Convener or a designee may complete this next section:

6.1 Required materials: Did the candidate provide all of the written materials and required by the Standards and the Supporting Documents checklist (Section 5, of this form)?

Yes, the candidate provided all of the certification materials. No, the candidate did not provide all of the certification materials

If No, then why not?

6.2 Quality of written materials From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of CPE Supervision.

Are the written materials well organized and reflect a graduate level of professionalism?

Critique the strength and weakness of candidate’s ability to provide Clinical Pastoral Education training via the required materials?

6.3 Quality of Demonstrated Competency Describe how the candidate demonstrated, during the face-to-face certification review process, congruence between their submitted materials and their ability to integrate theory, theology, unique personal history and use of self in their clinical practice.?

What were the strength and weakness of the candidate during the give-and-take process of the consultation?


6.4 Clinical Functioning

Briefly describe how the candidate demonstrates their ability to integrate their theory, theology, and unique personal history in their clinical practice.

6.5 Theoretical Comprehension Report your assessment of the candidate’s demonstrated proficiency, Competencies and skills required for the level of certification for which he/she is applying. Your assessment of the candidate’s knowledge of the core bibliography, including, but not limited to: crisis intervention theory and practice; grief and loss; interdisciplinary and interfaith pastoral care.


Section 7. Recommendation for Certification

The

Chapter has thoroughly reviewed and recommends

for board

certification. We attest that all of the candidate’s documents are complete and ready for review by the Review Panel, and that it is the chapter’s determination that the candidate meets the certification standards and is prepared to meet the Review Panel .

Candidate’s Signature:

Date:

Convener’s Signature:

Date:

Continued, next page.


Chapter Members Present at Review Date:


Certification Consultation Report for Diplomate Psychotherapist

This form is to be completed and submitted by an appointed member of the Chapter serving as one of the consultants. If the chapter has determined that the candidate is not yet prepared for certification (and is therefore not prepared to meet the Review Panel) this report does not need to be submitted but may be used for the chapter’s consultative process with the candidate. Please save the completed form to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – Chapter Consultation Report Form” or “Hernandez – Chapter Consultation Report Form”. Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), and please keep a copy for your records.

Section 1.

1.1 Today’s Date:











Cert Form – Diplomate Psychotherapist Page 2 of 208/01/16




1.13 Candidate is Board Certified Pastoral Psychotherapist with CPSP or other cognate group? Yes (see 1.14 and 1.15) No (skip 1.14 and 1.15)



1.16 Ethical and CPSP Commitment Evidence of high ethical commitment, including absolute respect for the worth and rights of persons. Level of commitment to CPSP’s mission and Standards as a means to provide an exceptional training program that represents CPSP well in the public domain. RESPONSE:



2.1 Degree(s): Master (M.Div.) Doctorate






2.7 List Training Units the Candidate supervised as an SIT

Training Center Name & Location Training Dates Supervisor’s Name

2.8 Has the Candidate completed an intensive residential Tavistock Group Relations Conference? Yes No If Yes, date(s) and location(s):

2.9 Has the Candidate completed a personal, therapeutic, psychodynamic journey in the service of self-understanding? Yes No




4.2 Read and initial: I, the candidate, understand that this certification must be renewed annually in March through chapter affiliation. If I allow this certification to lapse, I will not present myself publicly as a CPSP certified person. The CPSP Directory lists all certified and non-certified members of the College of Pastoral Supervision and Psychotherapy. Any persons representing themselves as CPSP certified and not listed in our directory are misrepresenting themselves.




5.1 Use the excerpt from the CPSP Standards (approved 03/16/16), below, to compile the supporting documents required.

640. Certification as CPSP Diplomate in Pastoral Psychotherapy A candidate who completes requirements for pastoral psychotherapy supervisor is eligible to meet with his/her chapter for examination of competency and proficiency (¶ 440). If the candidate fulfills criteria for supervisory status, and if the candidate is fully informed and committed to all expectations of participation in chapter life, then the chapter shall recommend the candidate for certification as a Diplomate in Pastoral Psychotherapy (¶ 440.4.1). Candidates for certification as a Diplomate in Pastoral Psychotherapy must submit supporting materials as required by the chapter, which includes but is not limited to the following:

640.1 A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of pastoral psychotherapy supervision. 640.2 A comprehensive theory paper delineating his/her supervisory theory, in compliance with academic writing standards. 640.3 Evidence of current state licensure or certificate to supervise, OR be approved by a cognate group to supervise in specific mental health disciplines, OR receive fifty (50) hours supervision of supervision. 640.4 Evidence of having completed a minimum of 30 contact hours of graduate-level course work in clinical supervision. 640.5 Evidence of having provided at least 150 hours of pastoral counseling supervision. 640.6 Exhibits from a single unit of supervised training, as follows:

640.6.1 Video recordings of one complete group supervisory session. 640.6.2 The syllabus of the unit in pastoral psychotherapy training supervised by the candidate. 640.6.3 Evaluations written by the candidate of all trainees who participated in the candidate’s supervised pastoral psychotherapy program. 640.6.4 Narrative of one trainee’s progressive development through the unit, with candidate’s assessment of the impact of both individual, group supervision. 640.6.5 Training supervisor’s evaluation of candidate’s supervised unit.

640.7 Evidence of faith group endorsement if appropriate (¶ 410.3). 5.2 Candidate will compile the documents into one file, a .pdf. for the Review

Panel.




6.1 Required Materials Did the candidate provide all of the written materials and required by the Standards and the Supporting Documents checklist (Section 5, of this form)?



6.2 Quality of Written Materials From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of CPE Supervision. Are the written materials well organized and reflect a graduate level of professionalism?





6.4 Clinical Functioning Briefly describe how the candidate demonstrates their ability to integrate their theory, theology, and unique personal history in their clinical practice.




The


for board

certification. We attest that all of the candidate’s documents are complete and ready for review by the Review Panel, and that it is the chapter’s determination that the candidate meets the certification standards and is prepared to meet the Review Panel.


Date:


Date:



Certification Consultation Report for Diplomate Supervisor This form is to be completed and submitted by an appointed member of the Chapter serving as one of the consultants. If the chapter has determined that the candidate is not yet prepared for certification (and is therefore not prepared to meet the Review Panel) this report does not need to be submitted but may be used for the chapter’s consultative process with the candidate. Please save the completed form to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – Chapter Consultation Report Form” or “Hernandez – Chapter Consultation Report Form”. Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), and please keep a copy for your records.

Section 1.

1.1 Today’s Date:












Cert Form – Diplomate Supervisor Page 2 of 208/01/16



1.13 Candidate is Board Certified Clinical Chaplain with CPSP or other cognate group? Yes (see 1.14 and 1.15) No (skip 1.14 and 1.15)












2.7 List CPE Units the Candidate supervised as an SIT

CPE Center Name & Location Training Dates Supervisor’s Name

2.8 Has the Candidate completed an intensive residential Tavistock Group Relations Conference? Yes No If Yes, date(s) and location(s):

2.9 Has the Candidate completed a personal, therapeutic, psychodynamic journey in the service of self-understanding? Yes No



5.1 Use the excerpt from the CPSP Standards (approved 03/16/16), below, to compile the supporting documents required.

540. Certification as CPSP Diplomate in Pastoral Supervision or Training Supervisor

A candidate, in consultation with his/her training supervisor, shall request a consultation with the candidate’s certified Chapter to determine the candidate’s readiness to present themselves and their work for certification as a Diplomate in Pastoral Supervision or Training Supervisor. (¶ 430).

540.1 Candidates seeking a consultation with their chapter shall submit supporting materials as required by the Standards, which includes all materials listed in the Certification Committee’s checklist, not limited to the following:

540.1.1 A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s journey and insights gained from the psychodynamic process. 540.1.2 A comprehensive theory paper of sufficient length to demonstrate the integration of personal, professional, theoretical, theological, and clinical competency in compliance with academic writing standards. 540.1.3 Exhibits from a single unit of supervised training, as follows:

• Video recording of one complete group supervisory session where a clinical case is presented. Training Supervisor candidates are to present a video recording of one complete supervisory session.

• A paper, not to exceed five pages, is to accompany the video that provides an analysis of the session and reflects the candidate’s use of self and one’s integrated use of theory and theology in their practice.

• The syllabus of the training unit presented for review. • Evaluations written by the candidate of all trainees who

participated in the candidate’s supervised unit and all evaluations written by the trainees.

• Narrative of one trainee’s progressive development through the unit, with candidate’s assessment of the impact of both individual and group supervision.

• Training supervisor’s evaluation of candidate’s supervised unit.

540.1.4 Evidence of faith group endorsement if appropriate (¶ 410.3).

5.2 Candidate will compile the documents into one file, a .pdf. for the Review Panel.




6.1 Required Materials Did the candidate provide all of the written materials and required by the Standards and the Supporting Documents checklist (Section 5, of this form)?



6.2 Quality of Written Materials From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of CPE Supervision. Are the written materials well organized and reflect a graduate level of professionalism?





6.4 Clinical Functioning Briefly describe how the candidate demonstrates their ability to integrate their theory, theology, and unique personal history in their clinical practice.




The


for board

certification. We attest that all of the candidate’s documents are complete and ready for review by the Review Panel, and that it is the chapter’s determination that the candidate meets the certification standards and is prepared to meet the Review Panel.


Date:


Date:

Supervisor’s Signature:

Date:



Certification Consultation Report for Pastoral Psychotherapist This form is to be completed and submitted by an appointed member of the Chapter serving as one of the consultants. If the chapter has determined that the candidate is not yet prepared for certification (and is therefore not prepared to meet the Review Panel) this report does not need to be submitted but may be used for the chapter’s consultative process with the candidate. Please save the completed form to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – Chapter Consultation Report Form” or “Hernandez – Chapter Consultation Report Form”. Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), and please keep a copy for your records.

Section 1. General Information’

1.1 Today’s Date:











Cert Form – Pastoral Psychotherapist Page 2 of 1008/01/16




1.13 Candidate is Board Certified Pastoral Psychotherapist with CPSP or other cognate group? Yes (see 1.14 and 1.15) No (skip 1.14 and 1.15)



1.16 Ethical and CPSP Commitment Evidence of high ethical commitment, including absolute respect for the worth and rights of persons. Level of commitment to CPSP’s mission and Standards as a means to provide an exceptional training program that represents CPSP well in the public domain. RESPONSE:









2.7 List below the names of accredited training program(s) by CPSP that candidate has been accepted into for training in pastoral psychotherapy:

Training Center Name & Location Training Dates Supervisor’s Name



5.1 Certification materials will be submitted as one file, a .pdf, for the review panel. Candidates for certification as a Pastoral Psychotherapist must submit supporting materials as required by the chapter, which includes but is not limited to the following: [Rev. 031616]

840.1 A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of pastoral psychotherapy. 840.2 Audio or video recordings of two complete psychotherapy sessions along with the candidate’s brief assessment of each session. 840.3 A comprehensive theory paper of sufficient length to demonstrate the integration of personal, professional, and clinical competence, addressing theories of personality, psychology, and theology. 840.4 A recording of a portion of a psychotherapy session not more than 15 minutes in length (to be played during the certification review). (See below, for details.) 840.5 Final evaluations of the candidate’s training process written by the candidate and the training supervisor. 840.6 Evidence of faith group endorsement if appropriate (¶ 410.3) [Rev. 031616]

Note: Section 840.4 will not be required.




6.1 Required materials: Did the candidate provide all of the written materials and required by the Standards and the Supporting Documents checklist (Section 5, of this form)?



6.2 Quality of written materials From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of pastoral psychotherapy.

Are the written materials well organized and reflect a graduate level of professionalism?





6.4 Clinical Functioning

Briefly describe how the candidate demonstrates their ability to integrate their theory, theology, and unique personal history in their clinical practice.




The


for board

certification. We attest that all of the candidate’s documents are complete and ready for review by the Review Panel, and that it is the chapter’s determination that the candidate meets the certification standards and is prepared to meet the Review Panel .


Date:


Date:


Date:


Cert Form – Consultation Report for SIT/TS Page 1 of 5

Certification Consultation Report for Supervisor-in-Training (SIT) or

Training Supervisor (TS) Program This form is be completed by an appointed member of the Certification Committee’s Consultation Panel. Please save the completed form to your computer, and place the candidate’s last name in the name of the file. For example: “Jones – Certification Committee’s Report Form” Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), the Candidate and please keep a copy for the Certification Committee’s records.

Section 1.

1.1 Today’s Date:


Please type it exactly as it should appear on the certificate or Directory



1.5 For SIT’s -- Training Supervisor’s Name:

For SIT’s -- Training Supervisor’s Email:

1.6 For TS’s -- Training Supervisor’s Name:

For TS’s -- Training Supervisor’s Email:



1.9 Select the category the candidate seeks: Authorization to begin as a Supervisor in Training Authorization to begin as a Training Supervisor Training Supervisor


2

Note: For those seeking authorization to begin as an SIT the chapter must have at least four Diplomates or four authorized SITs. Likewise for authorization to begin as a Training Supervisors in Training must have at least four members present for the consultation who are Diplomates under the 2016 Standards or have functioned as a Diplomate for at least 5 years under the previous Standards or four members who have been authorized as Training Supervisors in Training.

1.10 Name of Chapter providing the consultation:

Note: For consultation with those seeking to begin as SIT the chapter must have at least 4 SITs who have been approved to begin SIT training or 4 Diplomates. Likewise, for authorization to begin as a Training Supervisor the chapter must have at least four members present for the consultation who have been approved to begin as Training supervisors under the 2016 Standards or at least four Diplomates who have been certified for at least five years under the previous Standards.

1.11 Date of consultation with the qualified Chapter:

1.12 Chapter members present for the consultation (list):


Section 2.


2.2 Written and Video Materials From the review of the candidate’s written and video materials, please describe how the candidate integrates (or fails to integrate) their unique personal history, use of self, theology, theory of supervision and their clinical practice of CPE Supervision. Are the written materials well organized and reflect a graduate level of professionalism? Critique the strength and weakness of candidate’s ability to provide Clinical Pastoral Education training as demonstrated by the required materials? RESPONSE:

2.3 Demonstrated Competency Describe how the candidate was able (or not able) to demonstrate during the face-to-face certification review process congruence between their submitted materials and their ability to integrate theory, theology, unique personal history and use of self in their clinical practice of CPE supervision? What were the strength and weakness of the candidate during the give-and-take process of the consultation? RESPONSE:

4

Section 3.

3.1 Supporting Materials for Review Authorization to begin as an Supervisor In Training:

A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of clinical pastoral supervision.

A projected theory of supervision document outlining the theories you are considering in your work as an Supervisor In Training. (It is understood that this is not a comprehensive theory paper as that will develop through the candidate's training) A detailed clinical case that reflects one's pastoral competency and clinical acuity along with the candidate's analysis of the case. Final evaluations from self and supervisor of the candidate's final unit of CPE.

Authorization to begin as a Training Supervisor in Training:

A comprehensive autobiographical sketch, not to exceed ten pages, outlining the candidate’s own pilgrimage, including how his/her psychotherapeutic journey impacts upon his/her understanding and practice of clinical pastoral supervision.

A projected theory of supervision document outlining the theories you are considering in your work as a Training Supervisor in Training (It is understood that this is not a comprehensive theory paper as that will develop through the candidate's training) A detailed clinical case that reflects one's pastoral competency and clinical acuity along with the candidate's analysis of the case. Final evaluations from self and supervisor of the candidate's final unit of CPE.

See CPSP Standards, V.16, approved 16-Mar-2016.


Section 4.

4.1 Recommendation Did the Certification Committee grant or deny the Candidate’s request to enter a program of training as a Supervisor-in-Training or Training Supervisor?

Yes No If denied, pleased state why and list the areas of needed growth and development.

If the candidate is granted entry into a program of clinical supervision leading to certification, please provide comments that reflect on their continued growing edges:

RESPONSE:


Date:


Date:


Date:


Training Supervisor’s Report of Recommendation for CPSP Diplomate Supervisor Candidate

This form is to be completed and submitted by the SIT’s Training Supervisor(s). Please save the completed form to your computer, and please place the candidate’s last name in the name of the file. For example: “Jones – TS Report of Recommendation”. Send the completed form to Krista Argiropolis, Administrative Coordinator ([email protected]), and please keep a copy for your records.

Section 1.

1.1 Today’s Date:




1.5 Training Supervisor’s Name:

1.6 Training Supervisor’s Email:

1.7 Training dates of candidate’s presenting CPE training unit:

1.8 Number of units supervised by candidate:

Cert Form – Training Supervisor’s Report of Recommendation Page 2 of 208/01/16

Section 2. Training and Supervision

2.1 Describe the training structure provided by the SIT trainee, including onsite visits with their training group and institution, as well as the ratio of face-to-face and non-face-to-face supervision.

2.2 Did the SIT provide their trainees a CPE Program Syllabus that set forth the scope and requirements of the program, including training schedules, bibliographies, evaluation forms, etc.? Did each CPE Unit meet the minimum requirement of 300 hours of clinical time to 100 hours of Group and Individual Supervision provided their trainees.

2.3 As Training Supervisor for the SIT, describe the training structure provided including onsite visits with their training group and institution, ratio of face-to-face and non-face-to-face supervision and the ratio between individual and group supervision.

Cert Form – Training Supervisor’s Report of Recommendation Page 3 of 308/01/16



4.2 Read and initial: This candidate has met the CPSP Standards for education and training for the certification of Diplomate Supervisor of Clinical Pastoral Education. I recommend this candidate for certification. Training Supervisor’s Initials: