Application for Psychotherapy Membership Categories

Application for Psychotherapy Membership Categories

ACPE Membership is maintained by meeting association standards and ethics, payment of an annual membership fee, and the completion of the Accountability for Ethical Conduct Policy Form.

Individuals must join at the highest level of membership for which they are qualified.

Category	Description	Annual Fee
Psychotherapist Member	Fully licensed in one's state to practice as a mental health professional OR Previously certified as a Diplomate or Fellow in the American Association of Pastoral Counselors (AAPC)	$200
Practitioner Member	Currently in the licensure process in one's state to practice as a mental health professional OR Interested in ACPE Psychotherapy activities and initiatives OR Previously affiliated with AAPC as other than Diplomate or Fellow	$100
Retired Professional Member	Previously an ACPE Psychotherapist or Practitioner member and now fully retired OR Previously a member in good standing with AAPC and now fully retired	$0
Student Member	Currently enrolled in an advanced theology or mental health-related degree program	$60

ACPE Psychotherapists, Practitioners, and Retired Professionals are voting members and receive acpe.edu email addresses, online Micrsoft 365 accounts, access to The Journal of Pastoral Care and Counseling, listing in the public "Find a Psychotherapist" directory, ACPE News, an invitation to participate in ACPE Communities of Practice, and member rates to educational events.

Students are non-voting members and receive access to The Journal of Pastoral Care and Counseling, member rates to educational events, and ACPE News.

Membership and application questions should be directed to ACPE Membership Engagement and Continuing Education Coordinator Ruth McPhail Ubaldo at Ruth.McPhail-Ubaldo@acpe.edu.

General Information
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Email*
example@example.com
For which membership category are you applying?*

ACPE Psychotherapist: Open to individuals who are fully licensed in their state as mental health professionals OR who were previously certified as AAPC Diplomates or Fellows. Psychotherapist members are required to pay an annual membership fee of $200.ACPE Practitioner: Open to individuals who are in the licensure process in their state to practice as mental health professionals OR are interested in ACPE Psychotherapy activities and initiatives OR were previously affiliated with AAPC as a regular member, certified pastoral counselor, or other (non-Fellow/ Diplomate) membership category. Practitioner members are required to pay an annual membership fee of $100.00.ACPE Retired Professional: Open to individuals who were previously ACPE Psychotherapists or Practitioners and are now fully retired OR were previously members in good standing with AAPC and are now fully retired. Retired Professional Members do not pay membership fees.ACPE Student: Open to individuals currently enrolled in an advanced theology or mental health-related degree program. ACPE Student members are required to pay an annual membership fee of $60.00.
Which Psychotherapy eligibility requirement do you meet?

I am fully licensed by my state as a counseling or mental health professional.I was previously certified as an AAPC Diplomate or Fellow.I am both fully licensed and was certified as an AAPC Diplomate or Fellow.
Which Practitioner eligibility requirement do you meet?

I am currently in the licensure process in my state to practice as counseling or mental health professionals.I was previously affiliated with AAPC as a regular member, certified pastoral counselor, or other (non-Fellow/ Diplomate) membership category.I am interested in ACPE Psychotherapy activities and initiatives.
Which Retired Professional eligibility requirement do you meet?

I was previously an ACPE Psychotherapist or a Practitioner member and am now fully retired.I was previously a member in good standing with AAPC and am now fully retired.
What advanced theology or mental health-related degree program are you pursuing?
License Type: Check all that apply

Licensed Clinical Professional CounselorLicensed Clinical Social WorkerLicensed Independent Social WorkerLicensed Marriage and Family TherapistLicensed Marriage and Family Therapist- SupervisorLicensed Mental Health CounselorLicensed Professional CounselorLicensed Professional Counselor- SupervisorLicensed PsychologistKentucky Licensed Pastoral CounselorNew Hampshire Licensed Pastoral PsychotherapistNorth Carolina Fee-Based Practicing Pastoral CounselorTennessee Licensed Clinical Pastoral TherapistLicensed Associate CounselorNot applicableOther
Please upload a copy of your license.

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Certification

Previously certified as a Diplomate by AAPCPreviously certified as a Fellow by AAPCPreviously certified as a Certified Pastoral Counselor by AAPCOther
Would you like you like to be listed in the public "Find a Psychotherapist" directory on ACPE's website? If you choose to be listed, your center/company name, address, work phone number, ACPE email address, license and/or certification information will then be included.

YesNo
Mailing Address: Personal*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Center/Company (if applicable)
Company/ Center Address (for the public directory)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Accountability to Psychotherapist Ethical Guidelines

The ACPE Professional Ethics Commission is currently reviewing the ACPE Code of Ethics and considering revisions that might better encompass the counseling and mental health professions. In the meantime, we ask new Psychotherapist and Practitioner members to agree to adhere to the following (in addition to the ACPE Code of Ethics):
1. To maintain conduct consistent with the Psychotherapist Ethical Guidelines.
2. If licensed, to abide by all relevant licensing requirements in one's state.
3. If ordained by a faith body that endorses, to maintain good standing with one's endorsing community.
Can you certify that the above statements are true of you?

YesNo, not at this time
If so, please enter your name, today's date, and your signature in the fields below.

First NameLast Name
Today's Date

MonthDayYear
Date
Signature

Clear
Hold down your left mouse button and drag to sign your name or use your finger if you have a touchscreen.
If the Above Cannot be Certified:

Please complete this section only if the above cannot be certified. Upload a document that explains which of the items cannot be certified, why that is the case, and what steps you are prepared to take in order to fulfill the requirements and return to good standing (for example, renewing your license with the state). Each situation will be evaluated individually and will require follow-up communication with Ruth McPhail Ubaldo, Ruth.McPhail-Ubaldo@acpe.edu, once good standing has been reestablished.
Upload a Description of the Items that Cannot be Certified:

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ACPE Accountability for Ethical Conduct

We ask all ACPE members to certify the following on an annual basis:
1. No discipline or corrective action arising from a complaint of unethical or felonious conduct has been imposed on me, and no complaint against me for unethical or felonious conduct is pending in a civil, criminal, ecclesiastical, employment, or another professional organization's forum.
2. I have never resigned, been transferred or terminated, nor negotiated a settlement from a position for reasons related to unethical or felonious conduct.
Can you certify that the above statements are true of you?

YesNo, not at this time
If so, please enter your name, today's date, and your signature in the fields below.

First NameLast Name
Today's Date

MonthDayYear
Date
Signature

Clear
Hold down your left mouse button and drag to sign your name or use your finger if you have a touchscreen.
If the Above Cannot be Certified:

Please complete this section only if the above cannot be certified. Provide an account of the complaint including the forum, the charges, and the final outcome. Provide the names of people involved in the process whom you authorize to provide full information to ACPE representatives.

Prior actions are not an automatic bar to ACPE membership. Each situation will be evaluated on its own merits by an Accountability Review Committee composed of the Executive Director, the Chair of the Professional Ethics Commission (PEC), the Chair of the Certification Commission, the PEC legal consultant, and a designated Board member.

ACPE has the right to extend or deny membership regardless of previous complaints, other forum's findings or subsequent remedial actions according to the judgment of the named representatives to the Accountability Review Committee on behalf of the association. If denied, the applicant may resubmit an application at a later time. Decisions are final and binding on ACPE.
Upload an Account of the Complaint

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I Understand:

I understand that as a condition of ACPE membership, I will provide to the association timely notice of any complaint of unethical or felonious conduct filed against me. I agree to provide to the ACPE Professional Ethics Commission in a timely fashion the information it requests regarding the investigation, adjudication, dismissal, or settlement of such complaint. Failure to report or provide accurate, full, and truthful information may be grounds for discipline, including removal of ACPE membership.
Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Signature*

Clear
Hold down your left mouse button and drag to sign your name or use your finger if you have a touchscreen.
Optional Photo

We encourage all members to upload a photo to be used in the ACPE internal membership directory. Please upload a recent photo of you that meets the following specifications:
- Allowed file formats: .gif, .jpg, .png, .bmp.
- Maximum file size: 1 MB
- Picture dimensions should be square and a maximum size of 1000 px by 1000 px
Upload a Current Photo

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Optional Information

The ACPE is committed to attracting, developing, and advancing the most talented caregivers and students regardless of their race, sexual orientation, spiritual/religious practices, age, gender, disability status and any other dimension of diversity. The information below is not required. It is collected for statistical purposes to track the association’s progress of achieving a diverse membership. Thank you for taking the time to tell us about yourself!
Gender

FemaleGender Non-conformingGender QueerIntersexedMaleTransgender
Birthday

MonthDayYear
Date
Faith Group
Check all that apply

American Indian or Alaska NativeAsian or Southeast AsianBlack or African DescentHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther
Should be Empty:

Application for Psychotherapy Membership Categories

General Information