Clinical Pastoral Education Application

Applying For

Select Program:*

Level 1
Level 2
Extended Part-time CPE Program
Summer Intensive CPE Program
Residency CPE Program
Certified Education Student Program

Applicant Info

Name:*

First Middle Last

Mailing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone #:*

Email:*

U.S. Citizen*

Yes
No

Experience and Education

Spiritual or Religious Community Affiliation:*

Authorizing Body:*

Authorizing Body Representative (name/title):*

Ordained/Licensed/Appointed:

Date:

College Name / Degree / Date:*

Seminary Name / Degree / Date:*

Graduate School Name / Degree / Date:*

CPE Unit History

CPE #1

Date

Center Name

# of ACPE Certified Units

CPE #2

Date

Center Name

# of ACPE Certified Units

CPE #3

Date

Center Name

# of ACPE Certified Units

References

Academic

Name*

First Last

Title*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Spiritual or Religious Community

Name*

First Last

Title*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Personal

Name*

First Last

Title*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Long-Form Questions

1. Provide an account of your life*

Include, for example, significant and important persons and events, especially as they have impacted, or continue to impact, your personal growth and development. Describe your family of origin, current family relationships, and important and supportive social relationships.

2. Describe Your Spiritual Growth and Development*

Include, for example, the faith heritage into which you were born and describe and explain any subsequent, personal conversions, your religious vocational call, religious experiences, and significant persons and events that have impacted, or continue to impact, your spiritual growth and development.

3. Describe Your Work History*

Include a chronological list of jobs/positions/dates of employment and a brief statement about your current employment and work relationships.

4. Describe a “helping incident” in which you were the person who provided the help*

Include the nature and extent of the request, your assessment of the issue(s), problem(s), situation(s). Describe how you came to be involved and what you did. Give a brief, evaluative commentary on what you did and how you believe you were able to help. If you have had prior and recent CPE, please attach a copy of a recent verbatim as your 'helping incident' and add to the verbatim your own notes on how and what you learned from sharing this verbatim with your supervisor and/or peers. If you have had CPE, but it was more than two years ago, include a recent account of a helping incident, written up in a verbatim format. If possible, include feedback from religious/spiritual colleagues and/or administrative supervisor.

5. Describe Your Impressions of Clinical Pastoral Education*

Indicate, for example, what you believe or imagine CPE to be. Indicate if CPE is being required of you. Indicate any learning goals or issues of which you are aware and would like to address in CPE. Finally, indicate how CPE may be able to help you meet needs generated by your ministry or call to ministry. If you have had prior CPE, please indicate the most significant learning experience you had during CPE. State how you have continued to use the clinical method since your previous experience. Indicate strengths and weaknesses that you have as they relate to your ministry and your identity as a professional person. Indicate any personal and/or professional learning goals and issues that you have at this time and how you believe that CPE will help you to attain or address these learning goals and issues.

6. Describe Your Site Placement Preference*

If you indicated a site placement preference, please write about this preference. If you have a preference in placement sites, please elaborate on the factors important in how you came to that preference. (this answer may be used in determining your interviewing process and team of interviewers, so please include all factors important in your decision preference).

Application Fee

Application Fee*

Price: $50.00

The application fee is non-refundable.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Acknowledgements

Have you ever been convicted or pled nolo to a misdemeanor, a felony, or other crime?*

Yes
No

Consent*

I agree to the application policy.

I understand that neither my submission of this application, nor any subsequent invitation for an interview by a representative of Center for Spiritual Care and Education, constitutes an offer of enrollment in any of the Center for Spiritual Care and Education Clinical Pastoral Education Programs.

In the event that my application to a Clinical Pastoral Education program is denied, I understand that the Center for Spiritual Care and Education is not obligated to provide me with a reason for its denial.

I hereby give my consent to Grady Center for Spiritual Care and Education to access my CPE evaluations, supervisory personnel, and references about matters pertaining to this current application.

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