ection 1: Personal Information Title Gender (TO Mate O Female First name E-mail Marital Status O Married CO Remarried CO Sing! O Widowed 1 Divorced C1 Separated Upon completion, please return your application and supporting documents one of the following ways: - E-mail to CounselingDepartment@fotf.org ~ Fax to 719-548-4643 - Mail to Focus on the Family Attn: Counseling Dept. 8605 Explorer Dr. Colorado Springs, CO 80920 Last name Personal Phone Business Phone (FOF use only) Business Address Line 2 Zip code Mailing Address Line 2 Zip Code Group/Practice Name How long have you been married?Ifyou are or have been divorced or are separated, please explain the situation: ion 2: Edu 1. School (Most Recent) 1, Major (Most Recent) 1, Degree (Most Recent) 1, Dates Attended (Most Ri * * - ' 2 s g 9 3 8 g 3. School 3. Major 3. Degree 3. Dates Attended Additional: | 8 = 3 9 q 2. Dates Attended 4, Dates Attendedction 3: Church Afi Chureh; Denomination: List current or past ministry responsibilities [e.g., Pastor, Youth Director, Sunday School Teacher, Elder, etc.] and any accountability for your ministry Section 4: Professional Information What type of state issued mental health license do you have? License Number: Expiration Date: Do you have professi whom you consult? O Yes ONo Section 5: Counseling Preferences What types of clients do you counsel? [indicate age, marital status, & sex] nal colleagues with (0 MOR! Identify HAN 15 arzas of specialty in which you feel ESPECIALLY qualifiedSpecialties Adoption C2 Adoption/Trust Based Relatioral Intervention Certified 7 Adult Children of Alcoholics Alzheimer's/Dementia (7 Anger Management Anxiety (7 Assessment Testing 1 Attention Deficit (Hyperactivity) Disorder O Autism Spectrum (1 Bipolar Disorder 1 Blended (Step) Families CO Career (1 Chila/Physical Abuse O Children 0 Chronic Pain/ Ittne Clinical Supervision 1 Co-addiction/Codependency (family of addicts) CO Crisis/ Critical Incidents 1 Custody Evaluations 1 Depression 1 Disabilities (1 Dissociative Identity Disorder O Dome: (1 Eating Disorders Violence [1 Eye Movement Desensitization and Reprocessing (EMDR) CO Family (Finances 1 Forgiveness/Reconciliation 1 Gender Identity DO Geriatries/Elderly 1 Grandparenting O Grief DO aiviatps 1 Homosexual Issues sues O Infidelity 1 Leaming Disabilities CO Life Ccaching O Marriage CO Mediat.on/Conflict Resolution CO Men's Issues O Missionary Re-entry 1 Obsess.ve-Compulsive Disorder 1 Parentiag 1 Pastors and Ministry Families 1 Personality Disorders 1 Phone/Online Video Consult 1 Phobias O Play Therapy 1 Post-Abortion/ Abortion Minded CD Trauma/Post Traumatic Stress Disorder (PTSD) O71 Pregnancy CO Premantal 1 Prison/Probation 1 Process Addictions (various) 1 Psychosis/Severe Mental Illness C7 Rape Recovery 1 Reactive Attachment Disorder (RAD) CD Ritual Abuse Sexual Abuse [Perpetrators] 1 Sexual Abuse [Victims] 1 Sexual Addiction/Pornography 1 Sexual Problems CD Singleress C Spiritual Issues 7 Substance Abuse CO Teenagers C1 Domesic Violence 1 Womer's IssuesDo you have any specialties NOT listed? If so, what are they? What issues do you prefer NOT to treat? Do you speak any additional languages? ONo Oves ( ‘ion 6: Liability/ Malpractii What is your current Insurance expiration date? Have you ever been denied malprectice insurance ONo © Yes (explain) [I Have you ever had a malpractice claim/suit filed against you? ONo If yes, were there any disciplinary actions taken? By which agencies/government agencies/professional? For Psychiatrist Applicants Only What percentage of your practice is medication management only? What percentage of your practice is therapy? Section 7: Focus on the Family Experience and ExposureDo you listen to Focus on the Family broadcasts? ONo © Yes (tow often), (2 } Which books have been the most influential in your professional development? Section 8: Spiritual What is your definition of a Christian? How does one become a Christian? How would you describe your relationship with Jesus Christ?What is your basic view of scripture? is your basic view of spiritual warfare and its impact on emotional/psychological health? How do you use prayer/scripture in counseling? How do you see the church fitting into the counseling processWhat is your view of the Lord in the healing process? Do you utilize prayer imagery, hypnosis, "healing of memories", or visualization in your therapy practice? Explain how each is utilized. Do you practice repressed/recovered memory work? If so, explain. Section 9: Theological: Personal Convictions & Application to Professional Practice Do you integrate the theological/psychological in counseling? If so, how? [Please be thorough in your responses] The following areas relate to Focus on the Family's Core Values. Please be thorough in your response for both your beliefs and your professional practice as prompted by box A and box B of the questionnaire below.ABORTION A.) Theological Conviction: Please describe what you understand the Bible teach regarding Abortion. B,) Professional Application: Please give your specific approach in counseling regarding Abortion. DIVORCE A.) Theological Conviction: Please describe what you understand the Bible teaches regarding Divorce [Include Biblical reasons}.B.) Professional Application: Please give your specific approach in counseling regarding Divorce. REMARRIAGE A.) Theological Conviction: Please describe what you understand the Bible teaches regarding Remarriage [Include Biblical reasons]. B,) Professional Application: Please give your specific approach in counseling regarding Remarriage.HOMOSEXUALITY A.) Theological Conviction: Please describe what you understand the Bible teaches regarding Homosexuality. B,) Professional Application: Please give your specific approach in counseling regarding Homosexuality. MARRIAGE A.) Theological Conviction: Please describe what you understand the Bible teaches regarding Marriage [Include roles of husbands and wives]B.) Professional Application: Please give your specific approach in counseling regarding Marriage. PORNOGRAPHY/SEXUAL ADDICTION A.) Theological Conviction: Please describe what you understand the Bible teaches regarding Pornography/Sexual Addiction. B,) Professional Application: Please give your specific approach in counseling regarding Pornography/ Sexual Addiction.CHILD DISCIPLINE A.) Theological Conviction: Please d what you understand the Bible teaches regarding Child Discipline [Include your philosophy of spanking] B.) Professional Application: Please give your specific approach in counseling regarding Child Discipline. Feedback Please use this space for any feedback or comments which you would like to give us. What are your ideas on ways we may work together to improve the service and care we want to give to those in need?How did you hear about our Christian Counselors Network © Current CCN Counselor © AACC Conference © www.focusonthefamily.com © Alumni Network O Assemblies of God Referred Clinician O Other Recommendat Name E-mail Name E-mail Name Email Application Check List 1 Completed all 9 sections of the Application 1 Copy of current State Mental Health License and Expiration Date Copy of current Proof of Malpractice Insurance and Expiration Date 1 Your Resume/CSV L Referral Letter from a Clinical Colleague LD Referral Letter from an individual familiar with your Christian walk THANK YOU FOR COMPLETING THE APPLICATION! »*An administrative support fee of $129 will be collected upon application approval. This fee provides the technology for members to have a professional profile on our website, a Focus on the Family magazine subscription, a bi-monthly e-newsletter from our ministry, and the administrative support needed to administer the CCN.