STATE OF TENNESSEE
DEPARTMENT OF HEALTH
DIVISION OF HEALTH LICENSURE AND REGULATION
BOARD FOR PROFESSIONAL COUNSELORS, MARITAL & FAMILY THERAPISTS,
AND CLINICAL PASTORAL THERAPISTS
665 Mainstream Drive
NASHVILLE, TENNESSEE 37243
www.tennessee.gov
(800) 778-4123, ext. 25138 or (615) 532-3202, ext. 25138
APPLICATION FOR LICENSE AS A LICENSED PASTORAL THERAPIST
_______Exam
_______Endorsement
INSTRUCTIONS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Complete this application, have it notarized, and mail it to the above address. Type or print legibly.
Enclose a non-refundable check for $210, payable to the Board for Professional Counselors, Marital & Family Therapists, and Licensed
Pastoral Therapists.
If you are applying by endorsement as a fellow or diplomate of the A.A.P.C., disregard instructions 4 and 8 through 13 and do not complete
pages 2 and 5. Instead enclose, or have sent, proof of being a fellow or diplomate and proof of current A.A.P.C. membership.
If you are applying by endorsement as a certified member of the A.A.P.C., disregard instructions 3 and 8 through 13 and do not complete pages
2 and 5. Instead enclose, or have sent, two (2) notarized affidavits signed by certified mental health professionals attesting to your period of
service (5 year minimum) as a clinical pastoral therapist or pastoral counselor.
Enclose a certified photocopy of your birth certificate.
All applicants must complete the attached Declaration of Citizenship form.
Attach a recent (within the last twelve (12) months) “passport” style photograph to the front of this application.
Enclose, or have sent to the above address, two (2) original and recent letters typed on the signator’s letterhead. These letters must verify your
good moral character and ethics.
Have your graduate transcript(s) sent directly from the educational institution(s) to the above address.
Have the Pastoral Counselors Examination Service send proof of successful completion of their written examination directly to the above
address unless you have not yet taken the exam.
Enclose proof of successful completion of a practicum consisting of at least one (1) unit of full-time clinical pastoral education in a program
accredited by the Association for Clinical Pastoral Education.
Enclose proof of successful completion of an internship consisting of at least two (2) years of clinical pastoral therapy training.
Enclose a copy of your graduate school catalog.
Have your supervisor complete page 5 and enclose it or have it sent to the above address.
If you have ever been licensed in any other states as a Clinical Pastoral Therapist, enclose a copy of those state’s statutes and rules and
complete page 6. Also enclose a copy of your original licenses and renewal certificates from those states.
You will be registered to take the oral and/or the written exam (from the Pastoral Counselors Examination Service), and contacted accordingly.
NAME
First
Middle and/or Maiden
DATE OF BIRTH
Last
SOCIAL SECURITY #
You must put your social security number on this form for the application to be complete. State and federal law require social security numbers on this application.
Tenn Code. Ann. §36-5-1301(a), as authorized by 42 U.S.C. § 405(c)(2)(C)(i). The number will be used to verify your identity, to ask questions about your financial
responsibility, and for any other purpose allowed by state or federal law. When you provide your social security number on this application and sign the form, you are
agreeing that Department of Health may use your social security number in furtherance of federal and state law, for example, to collect delinquent fees
U.S. CITIZEN:
Yes_____ No_____
All applicants must complete the attached Declaration of Citizenship form
CURRENT HOME MAILING ADDRESS:
CURRENT PRACTICE ADDRESS:
HOME PHONE #
WORK PHONE #
E-MAIL ADDRESS: ____________________________________________________________________________________________
Do you wish to receive notification, including renewal notification, from the Department of Health via email? ____ Yes
____ No
List all states where you currently have or have ever had a Clinical Pastoral Therapy license.
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RDA 1786
COURSE WORK SUMMARY
All courses listed on this page must also appear on the transcript sent directly from your college or university to the Board’s
Administrative Office.
COURSE NAME
*CREDIT HOURS
INSTITUTION
CORE CLINICAL THEORY (15 hour minimum)
PASTORAL COUNSELING THEORY (15 hour minimum)
AREAS OF SPECIALIZATION (15 hour minimum, examples are psychodynamic psychotherapy, marital & family therapy,
cognitive therapy, and behavioral therapy)
DIAGNOSIS AND TREATMENT OF MENTAL DISORDERS
*Convert
all quarter credit hours to semester credit hours; # quarter hours x .67 = # of semester hours
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COMPETENCY INFORMATION
PLEASE ANSWER THE FOLLOWING QUESTIONS. If any answers to questions in this part are in the affirmative, attach an explanation on a separate sheet. In
support of your explanation, the final documents or orders from the issuing states, courts, and/or agencies must be submitted along with this application.
For the purposes of these questions, the following phrases or words have the following meanings:
1.
“Ability to practice clinical pastoral therapy” is to be construed to include all of the following:
a.
The cognitive capacity to make appropriate diagnosis or evaluation, exercise reasoned judgment, to learn, and keep abreast of professional
developments;
b.
The ability to communicate those judgments and information to clients and other health care providers, with or without the use of aids or devices, such
as voice amplifiers; and
c.
The physical capability to perform required tasks and procedures, with or without the use of aids or devices, such as corrective lenses or hearing aids.
2.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to; orthopedic, visual, speech and/or
hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional or mental
illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism.
3.
“Chemical substances” is to be construed to include alcohol, drugs, or medications, including those taken pursuant to a valid prescription for legitimate medical
purposes and in accordance with the prescriber’s direction, as well as those used illegally.
4.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather it means recently enough so that
the use of drugs or alcohol may have an ongoing impact on one’s functioning as a licensee or within the past two (2) years.
5.
“Illegal use of controlled substances” means the use of controlled substances obtained illegally (e.g., heroin, or cocaine) as well as the use of controlled
substances that are not obtained pursuant to a valid prescription or not taken in accordance with the directions of a licensed health care practitioner.
QUESTIONS:
1.
YES
NO
Do you currently have a medical condition which in any way impairs or limits your ability to practice clinical
pastoral therapy with reasonable skill and safety?
a.
If yes, are they reduced or ameliorated because you receive ongoing treatment (with or without
medications) or participate in a monitoring program?
b.
If you have any limitations or impairments caused by an existing medical condition, are they reduced
or ameliorated because of the field of practice, the setting, or the manner in which you have chosen to
practice?
[If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individual assessment of the nature, the severity, and the duration
of the risks associated with an ongoing medical condition so as to determine whether an unrestricted license should be issued, whether conditions should be imposed, or
whether you are not eligible for licensure.]
QUESTIONS:
2.
If yes, do they in any way impair or limit your ability to practice clinical pastoral therapy with
reasonable skill and safety?
Are you currently engaged in the illegal use of controlled substances?
a.
4.
NO
Do you currently use chemical substances?
a.
3.
YES
If yes, are you currently participating in a supervised rehabilitation program or professional assistance
program that monitors you in order to assure that you are not engaged in the illegal use of controlled
substances?
Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?
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RDA 1786
COMPETENCY INFORMATION CONTINUED
QUESTIONS:
YES
5.
If you have ever held or applied for a license or certificate to practice clinical pastoral therapy in any state, country, or
province, has it or was it ever been denied, reprimanded, suspended, restricted, revoked, otherwise disciplined,
curtailed, or voluntarily surrendered under threat of investigation or disciplinary action?
6.
If you have ever held staff privileges at any hospital or health care facility have they ever been revoked, suspended,
curtailed, restricted, limited, or otherwise disciplined, or voluntarily surrendered under threat of restriction or
disciplinary action?
7.
Have you ever been convicted of a felony or a misdemeanor other than a minor traffic offense?
8.
Have you ever been rejected or censured by a professional association?
9.
NO
In relation to the performance of your professional services in any profession:
a.
b.
Have you ever had settlement of any legal action rendered against you; or
c.
10.
Have you ever had a final judgment rendered against you;
Are there any legal actions pending against you or to which you are a party?
If you have ever held a license or certificate in any health care profession, has it ever been reprimanded, suspended,
restricted, revoked, otherwise disciplined, curtailed, or voluntarily surrendered under threat of investigation or
disciplinary action?
APPLICANT: FILL OUT THE FOLLOWING AFFIDAVIT IN THE PRESENCE OF A NOTARY PUBLIC
AFFIDAVIT AND RELEASE
I,
, of
(Applicant’s Name)
(City)
(State)
being duly sworn and identified as the person referred to in this application and signed photos attests to the truth of each statement made in said application. I further swear that I have
read and understand the statute and the Rules and Regulations, which were enclosed in the application packet, and agree to abide by them in the practice of clinical pastoral therapy in
the State of Tennessee.
I HEREBY:
SIGNIFY my willingness to appear to answer such questions as the Board may find necessary, which may include a full Board interview.
RELEASE to the Board, its staff, and their representatives, any and all documentation necessary now and in the future to establish my physical and mental capabilities to safely practice
marital and family therapy.
AUTHORIZE release, use of disclosure of otherwise HIPAA protected health information to the limited extent necessary for my application to receive full consideration up to and
including discussion in a public forum should that become necessary.
AUTHORIZE the board, its staff, and their representatives to consult with my prior and current associates and others who may have information bearing on my professional
competence, character, health status, ethical qualifications, ability to work cooperatively with others, and other qualifications.
RELEASE from liability the Board, its staff, and all their representatives and any and all organizations that provide information for their acts performed and statements made in good
faith and without malice concerning my competence, ethics, character, and other qualifications for licensure.
ACKNOWLEDGE that I, as an applicant for licensure, have the burden of producing adequate information for a proper evaluation of my professional, ethical, and other qualifications
and for resolving any doubts about such qualifications.
THIS CERTIFIES THAT THE INFORMATION SUBMITTED BY ME IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE
Sworn to before me this
DATE
day of
,
.
Affix Seal Here
NOTARY PUBLIC
My Commission expires
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VERIFICATION OF SUPERVISED EXPERIENCE
TO BE COMPLETED BY THE APPLICANT’S SUPERVISOR
PLEASE COMPLETE THIS FORM AND RETURN IT TO THE ADDRESS BELOW. TYPE OR PRINT LEGIBLY. ON YOUR
LETTERHEAD STATIONERY DESCRIBE THE SUPERVISED CLINICAL EXPERIENCE, INCLUDING ALL LOCATIONS.
ENCLOSE PROOF OF BEING AN APPROVED SUPERVISOR. AN APPROVED SUPERVISOR IS A CERTIFIED CLINICAL
PASTORAL THERAPIST WHO HAS MET ONE (1) OF THE THREE (3) FOLLOWING REQUIREMENTS:
1.
2.
3.
Is a diplomat of the American Association of Pastoral Counselors;
Is a fellow of the American Association of Pastoral Counselors who is under supervision of a supervisor; or
Is a Board approved clinical pastoral therapy supervisor who submits evidence of:
A.
B.
C.
Five (5) years full-time experience in clinical pastoral therapy practice and supervision;
One hundred twenty-five (125) hours of supervision specifically in the skill of providing supervision to clinical
pastoral therapists; and
A recommendation for Board approved supervisor status from the individual who provided supervision of the one
hundred twenty-five (125) hours listed above.
NAME OF APPLICANT:
NAME OF SUPERVISOR:
TITLE OF SUPERVISOR:
CLINICAL PASTORAL THERAPY LICENSE NUMBER OF SUPERVISOR NAMED ABOVE (IF LICENSED):
THE ABOVE APPLICANT HAS SUCCESSFULLY COMPLETED SUPERVISED CLINICAL TRAINING DURING THE PERIOD
,
TO
,
,
AS FOLLOWS:
1.
Total hours of CLINICAL CONTACT IN CLINICAL PASTORAL THERAPY provided by the applicant during the time
you supervised him/her.
hours
2.
Total hours of INDIVIDUAL SUPERVISION of this work (270 are required).
hours
____________________________________________________________________________________________________________
I CERTIFY THAT THE INFORMATION GIVEN AND THE ENCLOSED PROOF OF SUPERVISORY QUALIFICATIONS ARE
CORRECT AND ACCURATE.
SUPERVISOR'S SIGNATURE
SWORN TO BEFORE ME THIS
DATE
DAY OF
,
.
NOTARY PUBLIC
MY COMMISSION EXPIRES
SEND TO:
Affix seal here.
Board for PC/MFT/CPT
665 Mainstream Drive
Nashville, TN 37243
THIS PAGE MAY BE DUPLICATED IF NEEDED.
PH #3596
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RDA 1786
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
DIVISION OF HEALTH LICENSURE AND REGULATION
BOARD FOR PROFESSIONAL COUNSELORS, MARITAL & FAMILY THERAPISTS,
AND CLINICAL PASTORAL THERAPISTS
665 Mainstream Drive
NASHVILLE, TENNESSEE 37243
www.tennessee.gov
Toll Free (800) 778-4123, ext. 25138
Local (615) 532-3202, ext. 25138
CLEARANCE FROM OTHER STATE CLINICAL PASTORAL THERAPY LICENSING BOARDS
Please complete the top portion and mail this form to the regulatory board in each state where you hold or have held a license to practice
as a Clinical Pastoral Therapist. (If additional forms are required, this form may be duplicated.)
NOTE:
Some states require a fee for providing clearance information. In order to expedite your application, you may wish to
contact the applicable state or states.
I was granted
on
Lic. #
by the State of
Date
The Tennessee Board for Professional Counselors, Marital & Family Therapists, and Clinical Pastoral Therapists requests that I submit
evidence that my license in your state is in good standing. You are hereby authorized to release any information in your files, favorable
or otherwise, directly to the Tennessee Board for Professional Counselors, Marital and Family Therapists, and Clinical Pastoral
Therapists.
Date:
Signature:
SSN#:
Printed Name:
THIS PORTION IS TO BE COMPLETED BY STATE LICENSING BOARD
License Number:
Basis of Issuance:
License currently registered:
Derogatory Information on File:
If “yes”, please attach explanation.
Date Issued:
Examination:
National
Endorsement/Reciprocity
Other
Yes
No
Yes
Authorized Signature
PH #3596
(Rev. 9/13)
Other
No
Title
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State
Date
RDA 1786
STATE OF TENNESSEE
DIVISION OF HEALTH LICENSURE AND REGULATION
HEALTH RELATED BOARDS
665 MAINSTREAM DRIVE
NASHVILLE, TN 37243
DECLARATION OF CITIZENSHIP
MUST ACCOMPANY ALL APPLICATIONS FOR INITIAL LICENSURE OR REINSTATEMENT OF LICENSURE
The “SAVE Act” requires Tennessee Department of Health (including all Boards, Commissions, and contractors), along
with every local health department in the State, to verify that every adult applicant for a professional license is either a
U.S. citizen, a “qualified alien,” or a nonimmigrant who meets the requirements set out at 8 U.S.C. 1621.
I am a(n) _____________________________________
Healthcare Profession (Please Print)
___________________________________.
License number if applicable
Please Print Legibly
1.
2.
Name:______________________________________________________________________________
Last
First
Middle
Maiden_
Mailing Address: ______________________________________________________________________
3.
Phone Number: Home: (____)_____-______ Office: (____)_____-_______ Fax: (____)___-________
4.
I am a United States Citizen:
5.
I am a foreign national not physically present in the United States _____Yes _____No. If you answered yes, to this question
please sign this form in the presence of a notary and return it with your application. No further documentation is required.
6.
Applicants Claiming United States Citizenship MUST provide one of the following:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
7.
____Yes
____No
Tennessee Driver’s License, or photo ID issued by Department of Safety.
A valid driver license or ID issued by another state, provided its issuance requirements meet Department of
Safety criteria.
An official birth certificate issued by a U.S. state, territory, or other jurisdiction. Puerto Rican birth
certificates issued before July 1, 2010 do not count.
A federally issued birth certificate.
A valid, unexpired U.S. passport.
A report of birth abroad of a U.S. citizen.
A certificate of citizenship.
A certificate of naturalization.
A U.S. citizen ID card.
Any successor document to #’s a-i above.
SSN that the entity or local health department may verify with the Social Security Administration in
accordance with federal law.
If you checked “No” in question 4 please indicate from the list below which category applies to you: (circle one)
a)
b)
Permanent Residents
A nonimmigrant applicant for a professional or commercial license whose visa for entry into the United
States is related to such employment, or a nonimmigrant under the Immigration and Nationality Act (8
U.S.C. 1101 et seq.).
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c)
d)
e)
f)
g)
h)
Asylees who meet the qualifications set out in 8 U.S.C. 1158
Refugees who meet the qualifications set out in 8 U.S.C. 1157
Persons who have been “paroled into the United States,” under 8 U.S.C. 1182(d)(5) or whose deportation has been
withheld under 8 U.S.C. 1253.
Cuban or Haitian entrants as defined by section 501(e) of the Refugee Education Assistance Act of 1980
Persons granted conditional entry into the U.S. under 8 U.S.C. 1153(a)(7) before April 1, 1980, because of persecution
or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic
national calamity.
An alien who has been “battered” or subjected to “extreme cruelty” by a parent or spouse as defined by 8 U.S.C.
1641(c), and also meets the qualifications set out 8 U.S.C. 1641(c)(1)(B). Under the circumstances set out in 8 U.S.C.
1641(c)(2) and (3), victims’ children, or the parents of children who are victims, may also apply for benefits as qualified
aliens.
Applicants claiming qualified alien status (question 7 above), please submit two of the following forms of “documentation of identity
and immigration status” as determined by U.S. Homeland Security to be acceptable for verification through the SAVE program.
Common types of documents used to verify immigration status are listed below. (Note: If you can provide only one document, your
status will be verified through the U.S. Department of Homeland Security’s SAVE program):
I-327 (Reentry Permit)
I-551 (Permanent Resident Card or “Green Card”)
I-571 (Refugee Travel Document)
I-766 (Employment Authorization Card)
Machine Readable Immigrant Visa (with Temporary I-551 language)
Temporary I-551 stamp (on passport or I-94)
I-94 (Arrival/Departure record)
Unexpired foreign passport
WT/WB Admission Stamp in unexpired foreign passport
I-20 (Certificate of Eligibility for Nonimmigrant F(1) student status– “student visa”)
DS2019 (Certificate of Eligibility for Exchange Visitor (J-1) Status)
I affirm under the penalty of perjury that the above is true and correct.
Signed this _____ day of _________________, 20__.
_______________________________________________
Signature
Sworn to before me this _______day of _____________________, 20__.
__________________________________________________________
NOTARY PUBLIC
AFFIX SEAL HERE
My Commission Expires:_______________________________________
If an applicant is discovered to be an unqualified alien, or otherwise ineligible for benefits under the Act, all recurring benefits
provided to that applicant must be immediately terminated. Anyone who purposefully makes a false, fictitious, or fraudulent claim of
U.S. citizenship or qualified alien status will be liable under the Tennessee Medicaid False Claims Act, or Tennessee’s False Claims Act.
Any person who conspires to defraud the state or any local health department by securing a false claim allowed or paid to another
person in violation of the Act may be liable under Tennessee’s False Claims Act. Upon discovery of an applicant’s false, fictitious, or
fraudulent claim of U.S. citizenship, state governmental entities and local health departments must also file a criminal complaint with
the United States Attorney.
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