In order to be considered for membership, please fill out this form. There are eight sections to complete.

 

1. Personal Information

Married
Re-married
Single
Widowed
Divorced
Separated

2. Church Affiliation

Yes
No

Yes
No

3. Education

4. Employment Information

Intern or Non-Private Practice Application ONLY

5. Liability/Malpractice

LMFT
MFTI
LCSW
ASW
LPC
PSY

Yes
No

Yes
No

Yes
No

Yes
No

6. Spiritual Application – Please be thorough in your response.

7. Personal Convictions – Please give both your approach in counseling and what you understand the Bible teaches regarding the following issues. Please be thorough.

8. Additional Information

Please attach a copy of the following documents to this application:

Please attach two letters of reference, no later than two years old to this application. One letter of reference must be from your current pastor.

Yes