Certified Professional Counselor Supervisor (CPCS)
Initial Application - Part 1 of 2

Contact Details

Prefix

First Name *

Middle Name

Last Name *

Suffix

Primary Email *

This email address is used for your CCALP login and communications. ALWAYS use the same email address for CCALP activities. This email should be unique to you and you will need to be able to access it in case you need to do a password reset or identity verification.

Mobile Phone Number *

I would like to receive Text Messages related to my certification(s). I understand that I can reply STOP at any time to unsubscribe.

Mailing Address *

Mailing City *

Mailing State *

Mailing Country *

Mailing Zip Code *

Education & Professional Achievements

University Name

Please Select the High Degree You've Achieved

Please Specify the Degree Program/Major/Field of Study

LPC License Issued Date

LPC License Number

After submitting here, you will begin PART TWO. Your application is NOT complete until you provide the remaining details.