Certified Professional Counselor Supervisor (CPCS)
Recertification Application

Contact Details

Prefix

First Name *

Middle Name

Last Name *

Suffix

Email Associated with Your CCALP Account *

ALWAYS use the same email address for CCALP activity. This ensures that all of your form submissions, payments and exam scores are accessible when you log in.

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 *

Do you supervise others?

Why Type of supervision do you provide?

How many supervisees do you average per year?

Upload your CEs showing 12 hours of approved training/workshops inSupervision

Coursework to meet the requirement(s) for CPCS recertification must be obtained within three (3) yearsof application submission.All trainings must be Synchronous or Live; no recorded webinars are accepted as CEs.

6 CE hours in Ethics for Supervisors *

5hrs CE hours in Documentation for Supervisors or other Supervision Topics of your choosing. *

Acknowledgment & Attestation Statements

I attest that I have read and agree to the following:

I acknowledge my responsibility to adhere to all laws/rules governing LPCs in Georgia.
I will maintain my LPC license in good standing with the GA Composite Bdof LPC, SW and MFT.
I voluntarily applied to CCALP for certification as a Certified Professional Clinical Supervisor.
My application is subject to the rules, bylaws, and other governing provisions of CCALP.
I agree to abide by the policies and regulations of CCALP as a CPCS once certified.
I recognize that CCALP may decide that I am not qualified, and I agree to abide by that decision.
I understand I have the right to appeal if I am not qualified and start a formal appeal with CCALP.
I agree to surrender my certification/candidacy if found in violation of the above by CCALP

By my signature, I attest that the information I submit herein or in any required accompanying or subsequent documentation is true and accurate to the best of my knowledge. I understand that persons who apply for certification are subject to CCALP ’ s eligibility requirements for certification and recertification. *

Clear

Certification Fee *

CPCS Recertification Application

$125