US Agency for Christian Counseling Credentials and Accreditation 5205 South Orange Avenue # 202, Orlando, FL 32809

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1 US Agency for Christian Counseling Credentials and Accreditation 5205 South Orange Avenue # 202, Orlando, FL Licensing & Certification The US Agency for Christian Counseling Credentials and Accreditation grants the following Christian Licenses and certifications based on the interested individual meeting the qualifications as set by the US Agency for Christian Counseling Credentials and Accreditation Licensing & Certification s Board. A. Licensed Christian Clinical Counselor B. Licensed Christian Counselor C. Licensed Christian Marriage and Families Counselor D. Licensed Pastoral Counselor E. Certified Christian Clinical Counselor F. Certified Christian Counselor G. Certified Christian Temperament Counselor H. Certified Pastoral Counselor The applicant shall pay $25.00 to the US Agency for Christian Counseling Credentials and Accreditation for the license application package and $ to be submitted with the application package for the license. License is annually renewable for a fee of $ upon submission of appropriate documentations as: Active Ministerial Credential, completion of 20 CEU s and other requirements set by the Board. 1

2 US Agency for Christian Counseling Credentials and Accreditation (Application for license/certification) (Please print/type all information clearly) Date US ACCCA Member NO.. (if applicable) 1. PERSONAL Name ( Last) (first) (Middle) Date of Birth / / SSN: / / Mailing Address: (Street) (City) (State) (Zip Code) Phone Numbers ( ) Home ( ) Office ( ) Cellular Address: Gender Religious Endorsing Body Race: (for Demographics) Caucasian African American Hispanic Other Highest degree Achieved II. REFERENCES: Give the complete names, address and phone of four (4) persons. At least three (3) of your references must be persons engaged in the counseling and /or pastoral fields. One of whom has known you a minimum of five (5) years. Supervisor: 2

3 Supervisor: Supervisor: Co-Worker or Professor: Have you ever been under disciplinary action by any professional/ ministerial organization or licensing board, or have you ever had a felony conviction? Yes No if is yes, please attached a brief description of the issue and the action taken. III. CURRENT PROFESSIONA/MINISTERIAL COUNSELING PRACTICE AND BRESPONSIBILITIES. A. Professional Practice: Private Group Agency Name of Practice or Agency: Position/Title: How Long? Address: Phone Number ( ) Description of your work: 3

4 IV. Attach to this application a copy of the following documents: Active Ministerial Credential, Driver License, Theological Seminary, College and/or University Official Transcript and your resume. V. EDUCATION: AREA 1: CORE CLINICAL THEORY REQUIRE COURSE WORK: Minimum of REQUIREMENT/HOURS Counseling and Psychotherapy: Theory & techniques Group Dynamics: Theory & Techniques Marriage & Family Systems: Theory & Techniques Social & Cultural Diversity Ethics & legal issue in Counseling Theory of human Development Personality s theory or temperaments Evaluation: Diagnostic procedures & coding Psychodynamic Psychotherapy Marriage and Family Therapy Cognitive Therapy Behavior Therapy Brief Therapy Group Therapy Career Development Substance abuse counseling TRANSCRIPT COURSE NUMBER AND NAME semester hours INSTITUTION 4

5 FFIDAVIT State Of: County Of: I, do solemnly swear that I am the applicant named in this application, that I have made and /or read the contents thereof and to the best of my knowledge and belief, the foregoing answers and statements are true and correct. I voluntarily consent to allow the US Agency for Christian Counseling Credentials and Accreditation, and any of its officers, employees, and agents to check my references by contacting any person listed as reference on this application and /or accompanying this application, and to release US Agency for Christian Counseling Credentials and Accreditation, and its officers, employees, and agents from any or all liability for obtaining this information. I understand that these questions may be about my educational background and work experience. Furthermore, I release all my previous employers and any reference listed on and/or accompanying this application from any and all liability for providing accurate, job-related and/or education related information as necessary. I agree that abuse of alcohol and/or other drugs, and/or any behavior in violation of the code of Ethics is not acceptable behavior for a counselor and, should circumstances indicate, I may be subject to additional review by the Licensing Board. I understand that the fee submitted herewith represents the preliminary application fee. The Board will require an additional fee for Licensing, coincident to the application and Licensing process. I further agree to hold the US Agency for Christian Counseling Credentials and Accreditation and its Licensing Board members, officers, agents, staff and examiners free from any civil liability for damages or complaints by reason of any action that is within the scope and arising out of the performance of their duties which they, or any of them, may take in connection with this application, the attendant examinations and the grades with respect to any examination, and/or the failure of the Board to issue me said License. I hereby affirm that I have read and agree that I will abide by the US ACCCA code of Ethics, and I agree to submit to proceedings for any alleged violation of the same in accordance with the USACCCA Constitutions and By-Laws. I understand that falsification of the contents of this application will be ground to denial and/or revocation of License, membership, and any and all benefits resulting there from. Signature of Applicant Date Signed NOTARY USE ONLY (required): Subscribed and Sworn to before me this day of 200 My Commission Expires: Notary Public 5

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