Counselor Application – Temporary

Name (required)

Street Address (required)

City & Zip (required)

Cell Phone (required)

Home Phone

Work Phone

Email Address (required)

Referred by:

I am applying as a: (required)
MFT TraineeAssociate MFTAssociate CSWPCC TraineeAssociate PCCMSW StudentParaprofessional* (not counting hours toward a license)

*IF YOU ARE APPLYING AS A PARAPROFESSIONAL, YOU MUST HAVE COMPLETED THE COMMUNITY COUNSELOR CERTIFICATION PROGRAM. Please enter your date of completion:

My graduate school (if applicable) is:

Is your school COMFTE accredited?
YesNo

Does your school require a number of relational/couples/family hours within your first year of training?
YesNo

Our application is designed to give us a chance to get to know you: how you see yourself, important influences on you and your life, your views on how you became the person you are today and the person you hope to become. We want to see whether you and the Center are a good match. Please be assured that the material you submit will be held in strict confidence. It will not be returned.

The following questions are required.
Please upload a separate document for each of Questions 1-3, along with a resume:

1. WRITE AN AUTOBIOGRAPHY (2-3 pages double spaced). Many experiences influence who we are. Please tell us some of the important experiences you’ve had that have shaped you, influenced you, and led you to the decision to become a counselor. We want this to be personal. Include important people, significant relationships, and cultural influences that have made you the person you are. (required)

2. PROVIDE A PERSONAL THERAPY STATEMENT (1-2 pages double spaced). We believe that personal therapy is an essential part of the process of becoming a counselor. Please tell us about any therapy you have engaged in, for how long, and how it influenced your life. If it helped, how do you think it helped? What have you valued in therapists you have worked with? What has not been helpful? (required)

3. HOW AWARE ARE YOU OF DIFFERENCE (1-2 pages double spaced)? Please describe an experience from your past that shows how you’ve coped with feeling different or ‘othered’ socially, systematically, or relationally. (required)

4. Please upload a resume (required)

Please provide the following information:

Have you ever been the subject of any disciplinary investigation or criminal charge?
YesNo

Has any claim ever been made alleging unethical or unprofessional conduct on your part?
YesNo

If you answered "yes" to either of the above two questions, please state the nature of the investigation, charge or claim, the date made and disposition. (There will be an opportunity during your interview to discuss this.)

Have you ever been a client of the Southern California Counseling Center? (required)
YesNo
If so, on what date did you terminate?

Have you ever worked as a counselor or group facilitator in any program at the Southern California Counseling Center? (required)
YesNo
If so, in what program and what date did you terminate?

Have you ever taken training programs at the Southern California Counseling Center? (required)
YesNo
If so, in what program and when did you terminate?

I have read through and can commit to the requirements stated in the SCCC Counselor Applicant Fact Sheet.