FamilyLife Canada Counsellor Application
Thank you for your interest in having your practice listed on the FamilyLife Canada website we value your partnership in offering help and hope to marriages and families. This application consists of three parts:
1. General information and qualifications
2. Agreement with the FamilyLife Statement of Faith (https://www.familylifecanada.com/beliefs/) and Code of Conduct
3. Contact information for one personal and one professional reference (a URL will be provided for them to submit an online reference form on your behalf)
Sign in to Google to save your progress. Learn more
Email *
Contact Information
For correspondence with the FamilyLife Canada Office.
First Name *
Last Name *
Phone Number *
Public Contact Information
As you'd like it to appear on the FamilyLife Canada website
Full Name (including any designations you'd like to note) *
Company Name
City, Province *
Phone Number (if different than above)
Email address (if different than above)
Website
If applicable, please indicate the name of the person who referred you
The following questions are for internal purposes only and will not be shared publicly.
Gender *
Date of Birth *
MM
/
DD
/
YYYY
What role does personal faith in God and Jesus Christ play in your life and practice? *
Do you attend church regularly *
If Yes, which church/denomination? *
Are you a full time counsellor? *
If No, what other work or ministry are you involved in?
How long have you provided counselling? Years/Months *
Have you provided counselling to people in ministry? *
Are you currently registered or licensed as a professional therapist? *
If Yes, whom are you registered with? Provincial/National/Religious and Name of Association:
Educational Background: Please list all schools attended, including: Bible Colleges, Seminaries, and Universities. Indicate level of achievement or certificate(s) obtained (e.g. Diploma, B.A. Degree). Or if you prefer, you can instead provide a link to your LinkedIn profile or webpage that lists these credentials.
Have you ever been investigated or dismissed from a position as a result of any misconduct (e.g. sexual, conflict of interest, unethical behavior of any kind?) *
If Yes, please provide the necessary details that may pertain to counselling
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Power to Change. Report Abuse
Google Forms