CPE/T Application Form

Contact & Basics

First name

Last name

Email

Phone

City

State/Province

Country

Faith Group Affiliation, if any

How did you hear about our program?

Eligibility & Track

Highest Degree Completed

Chaplaincy/clinical background, if any

Track Preference

Regular - 12 week units

Extended - 24 week units

Placement Plan

Do you have a potential local clinical placement site?

Yes

No

Maybe

Scheduling Feasibility (hours per week; days/times

On-Call Openness

Yes

No

Not Sure

References

Reference #1 - Name, Email, Phone, Relationship, Years Known

Reference #2 - Name, Email, Phone, Relationship, Years Known

Accessibility & Scholarships

Accessibility needs for online learning (short paragraph; no medical details)

Scholarship Need

Yes

No

If yes, please provide Need Statement below (less than 150 words)

Agreements & Uploads

I understand this is a Clinical Training Program with the following requirements:

Learning Contract (by week 2) with individualized goals tied to program competencies.
Individual Supervision - Regular: 1-hour weekly regular / Extended: 1-hour bi-weekly
Group Supervision Regular: 1-hour weekly / Extended: bi-weekly
Pre‑Supervision Journal (one page before each individual supervision session).
Case Studies (including a verbatim excerpt) – Regular: 8 full cases (≈bi‑weekly) per unit; Extended: 8 full cases (spaced across the unit).
Theory‑to‑Practice Paper – Unit 2 draft; Unit 4 final (board‑readiness). If completing a single stand‑alone unit, submit an Integrative Reflection (≈1,200–1,800 words).
Mid‑Unit Self‑Assessment & Supervisor Review (week 6 regular / week 12 extended).
Final Evaluations (self, supervisor, and—where available—site feedback).

On all uploads, do not include protected health information or patient identifiers.

RESUME / CV

AUTOBIOGRAPHY - provide a reflective autobiographical account of your life, giving attention to pivotal life events and relationships that have shaped you as a person.

HELPING INCIDENT - describe a situation where you provided help to someone(s) facing a difficult life situation. Supply a reflective critique of your intervention. Applicants with previous CPE will address by providing this a clinic case.

HOPES & ASPIRATIONS - what do you hope to gain from Clinical Chaplaincy training?

UNOFFICIAL TRANSCRIPTS (optional)

Signature

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Equipping Chaplains.

Strengthening Institutions.

Transforming Care.™