CSCPF Request for Certification

Request for Certification
Congratulations for all that you have accomplished! This form allows you to begin the process that can lead to your becoming certified by the CSCPF community.

For all categories of CSCPF certification, Certification Standards Excerpts and related Application Checklists are available here.

Here is a synopsis of the certification process:

1. You should have already joined CSCPF and be active in a CSCPF Practitioner Community, and be current in your dues. Do not proceed further if this is not the case.

2. You should have already reviewed your certification materials with your Practitioner Community Certification Representative. Do not proceed further if this is not the case.

3. You should have already submitted the Application for Certification. Do not proceed further if this is not the case.

4. Complete and submit this Request for Certification and your payment. For your Request for Certification to be processed you must pay your fees below. This includes submitting PDF versions of the required materials for the certification category you desire (see each specific Certification Standards Excerpt).

Please Note: An additional $150, payable to the Commissioned Review Liaison assigned to your panel, will be due at the time of your panel.

5. You and your Practitioner Community will assemble a Practitioner Community Certification Review Board, you will choose a Commissioned Review Liaison and possibly a mentor, and then schedule the appropriate preliminary reviews and formal Certification Review Board.

6. The formal Certification Review Board will meet with you and the Commissioned Review Liaison and Scribe. You will be notified of their decision the day of your Certification Review Board.

7. Your Practitioner Community Certification Representative will submit a Notice of Decision to CSCPF.

8. If you are certified, the Certification Team will send the certificate to your Practitioner Community for the final signature by your Practitioner Community Liaison.

This Request for Certification will be received by the Certification Team then sent directly to your Practitioner Community Certification Representative. You must have their email address at hand, as well as the required documents in PDF form.

Please note: Your CPE evaluations are considered confidential documents and should be sent via email to your individual Practitioner Community Review Board members and NOT attached to this form.

All of the information on this form is important for your review. If you have any questions, please email us at CSCPF-Certification@cscpf.org or call 925-658-5740 and select option 4.

About Your Practitioner Community
Practitioner Community Name
Practitioner Community Certification Representative Contact Info (email address)*
This should be different from the candidate's email address.

Information About You, the Certification Candidate - Part 1
Name*

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone

Area CodePhone Number
E-mail*

Confirmation Email

Certification Request Information - Part 2
Which certification category(ies) are you seeking? Check all that apply.
Category(ies)*

Associate Chaplain / Associate Spiritual Care PractitionerAssociate Pastoral Counselor / Associate Spiritual Care CounselorClinical Chaplain / Spiritual Care PractitionerPastoral Counselor / Spiritual Care CounselorClinical Specialist: Palliative/Hospice CareSupervisor - Clinical Pastoral Education / Formation

Formation Information - Part 3
CPE Units Completed*
(i.e. date completed, Learning Center name, supervisor's name, serving site name and location. Use 1 line for each CPE unit.)
Existing Certifications
(i.e. date of certification, name of certifying body, category of certification. Use 1 line for each certification.)
Ministry Experience
Please briefly describe any ministry experience, particularly in the area of spiritual care.

Educational Information - Part 4
Please indicate the degree awarded, year, school, and major area of study. Note that you may enter "Equivalency" as appropriate for the AA/BA and MDIV levels, which are the only required fields.
AA/BA*
(i.e. date, degree, educational institution, major/minor departments)
MDIV*
(i.e. date, degree, educational institution, area of focus)
Masters (Other than MDIV)
(i.e. date, degree, educational institution, area of focus)
Doctoral
(i.e. date, degree, educational institution, area of focus)
Email
example@example.com
Other
(i.e. date, degree, educational institution, area of focus)

For Certification as Clinical Specialist: Palliative/Hospice Care ONLY - Part 5 (If not requesting this certification, please go directly to Part 6)
We recognize there may be many paths to becoming a Clinical Specialist: Palliative/Hospice Care. All Clinical Specialist applications will be reviewed on a case-by-case basis. Per the Standards for this category:

• The candidate must currently be a CSCPF Board Certified Clinical Chaplain or a CSCPF Board Certified Pastoral Counselor in good standing.

• All Clinical Specialist applications (except Reciprocal Certifications) must include an integration paper addressing his or her competence in each of the standards (including clinical examples) that demonstrates a mature level of self-awareness, honest and balanced self-reflection, and an integrative understanding of one's own psychodynamic and spiritual development.

• The candidate must have completed a minimum of 400 additional hours of work as a Chaplain or Pastoral Counselor in the Clinical Specialty of Hospice and/or Palliative Care, and can meet the standards and competencies as listed in the Standards below. This requirement may be met in one the following ways:

• Path 1: Completion of an additional accredited formal unit of CPE or Fellowship in a hospice or palliative care setting, including a minimum of 40 hours of Palliative Care/Hospice interdisciplinary team case conferences.

The candidate must provide an evaluation(s) from their Supervisor and submit a self-evaluation.

• Path 2: Completion of Clinical Specialty training in the context of a mentoring/case conference/group process model, consisting of a minimum of 400 hours of work as a Clinical Chaplain or Pastoral Counselor within a hospice or palliative care team under mentoring of one or more Clinical Chaplains or Pastoral Counselors preferably certified in the specialty of hospice and palliative care, including a minimum of 40 hours of Palliative Care/Hospice interdisciplinary team case conferences.

• Path 3: Meet the CSCPF Equivalency Requirements for Clinical Specialist: Palliative/Hospice Care for those who have done significant* work, training and/or coursework in a hospice and/or palliative care setting.

*”Significant” means a minimum of 400 hours of work as a Clinical Chaplain or Pastoral Counselor within a hospice or palliative care team under mentoring of one or more supervisory Chaplains or Pastoral Counselors preferably certified in the clinical specialty of hospice and palliative care, including a minimum of 40 hours of Palliative Care/Hospice interdisciplinary team case conferences.
What "Path" are you applying under?

Path 1Path 2Path 3Other
Submit a PDF of your integration paper

Browse Files

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If "Path 1": Please state where, when and with whom you completed your CPE training. Submit via email, your evaluation(s) from your Supervisor and your self-evaluation.
If "Path 2": Please state the name of your training program, where, when and with whom you completed your training. Submit via email, your evaluation(s) from your Supervisor and your self-evaluation.
If "Path 3": Please detail your work experience - where, when and with whom. Submit via email, an evaluation(s) from your Supervisor and your self-evaluation.

Spiritual Community / Faith Tradition / Denomination - Part 6
Name
Please identify your spiritual community /spiritual tradition in your preferred terms.
Authority
If appropriate, please provide the name and title of your community's leader.
Location
Ministry Position
Do you function in ministry within your spiritual community?
Ministry Type

OrdainedEndorsedAppointed
From Date

MonthDayYear

Uploads and Submit
Uploads - Please limit this to PDF's containing the materials required in the checklist. Your Practitioner Community may request additional items. Please note: Your CPE evaluations are considered confidential documents and should be sent via email to your individual Practitioner Community Review Board members and NOT attached to this form.*
Your Email
NOTE: When requesting certification in multiple categories, you must list each category requested in the box below the payment method.
Please list all the categories you are requesting to be certified. (e.g. Clinical Chaplain, Assoc Clinical Chaplain, Pastoral Counselor, Assoc Pastoral Counselor; Clinical Specialist: Pal/Hospice Care etc)*
Please list all categories for which you are seeking certification.

My Products

Certification Fees - REQUEST for CERTIFICATION$100.00

Certification Fees - Add'l Certification Category Fee #1 $50.00

Certification Fees - Add'l Certification Category Fee #2 $50.00

Certification Fees - Add'l Certification Category Fee #3 $50.00

Certification Fees - Add'l Certification Category Fee #4 $50.00

Resubmission of documents ONLY$ Free

Enter coupon

Total $0.00

Email
example@example.com

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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