www.cpe-toronto.ca
Clinical Psychospiritual Education (CPE) 
BASIC Application
Important: Download this form and save a copy of your application before submitting it by email.
Personal Information						Date: ____________
Last Name		
First Name:		
Street Address:		
City/Town:		
Postal Code:		
Phone:				
Email Address:		
University of Toronto student number:		

Current Student Status
All students must be enrolled in a degree program with a University or College that has a placement agreement with the teaching hospital. Fees will be paid by the student to their college through the registration system. Proof of registration is required to begin CPE. A student must apply to the teaching hospital directly, appear for the interview, and receive a letter of offer from the teaching hospital before enrolling in their educational institution’s registration system. 

Details of Current Educational Program Enrollment 
Which educational institution are you currently enrolled in? 		
Theological School:		
Degree:		
Graduation Year:		

Previous Education
In this section, outline your post-secondary education, including your university degree, theological degree (if applicable), and other relevant degrees.
College/University:		
Degree Received:		
Graduation Year:		

College/University:		
Degree Received:		
Graduation Year:		

College/University:		
Degree Received:		
Graduation Year:		

Past Work Experience (or attach a Resume)
Job title/description	Company/location	Employment dates	

			

Faith Group Information
Spiritual Association
Faith group/religion:		
Describe your current and past involvement in your spiritual community, i.e.  congregation, house church, religious order, synagogue, Mosque, Temple,
If you do not have a spiritual community, briefly describe your spiritual journey:		

Course Information
List the Teaching Centre to which you are applying in order of preference and the dates for the specific unit. You are encouraged to apply to more than one Centre if your first choice is unavailable.
Type of CPE Unit (Check One) 
Basic Unit 1	Basic Unit 2	

First Choice
Teaching Centre:		
Dates: (Day/Month/Year)- (Day/Month/Year)		
Note: It may not be possible to place you in a specific location in multi-location centres.
Second Choice
Teaching Centre:		
Dates: (Day/Month/Year)- (Day/Month/Year)		
Note: It may not be possible to place you in a specific location in multi-location centres.

List past Clinical Psychospiritual Education (CPE) or Psychospiritual Therapy Education (PTE) units 
If applying for Basic Unit 2, include a copy of your self-evaluation and your supervisor’s evaluation for Basic Unit 1.
CPE/PTE Unit #1
Institution/Centre:		
Supervisor:		
Year Completed:		

CPE/PTE Unit #2
Institution/Centre:		
Supervisor:		
Year Completed:		

CPE/PTE Unit #3
Institution/Centre:		
Supervisor:		
Year Completed:		

Previous CPE/PTE units not completed.
Institution/Centre:		
Supervisor:		
Date:		

References
Please enter the names and contact information for three references: two persons to whom you were responsible as a student, employee, or volunteer, and one from a spiritual leader of your faith group. 

Reference #1
Name:		
Street Address:		
City/Town:		
Postal Code:		
Country:		
Phone:				
Email Address:		
Position:		

Reference #2
Name:		
Street Address:		
City/Town:		
Postal Code:		
Country:		
Phone:				
Email Address:		
Position:		

Reference #3
Name:		
Street Address:		
City/Town:		
Postal Code:		
Country:		
Phone:				
Email Address:		
Position:		

The Following Essays and a Resume must be included in the completed application:
 (See CASC Manual; Chapter 2: Education)
1. Autobiographical Narrative: (750-1500 words, double-spaced with 12 pt. font) 
Describe your family of origin, current family relationships, and important supportive social relationships. Give examples of significant events describing how these have impacted your personal growth and development. Describe how your life history influences who you are personally and professionally.

2. Spiritual Care Identity and Areas of Continued Growth (750-1500 words, double-spaced with 12 pt. font)
Describe your definition of spiritual caregiving. Describe the ways in which your spiritual and religious beliefs and practices have changed over your lifetime.
Describe your present growing areas both theologically and spiritually.
3. State your reasons, hopes, and goals for taking this unit of CPE. (750-1500 words, double-spaced with 12 pt. font) See the CASC Manual for the list of core competencies. 
What are the three main learning goals that you want to address in a unit of CPE?
What prompted you to apply for CPE at this time?
In what ways do you think CPE will impact your personal and professional career?

Submit your Application 
I confirm that, to the best of my knowledge, all the information in this application is correct.
Name:		
Signature: 		
Email:		
Telephone: 		
Date Submitted:
(Day/Month/Year)		

Please note:
•	Acceptance into a CPE program requires membership in CASC – Please go to https://www.spiritualcare.ca/benefits--categories.html  to apply for membership. Basic Student membership fees are currently $90.00 per year. You will not be able to receive your certificate unless you have paid your membership!
•	You will be required to adhere to the admission policies of the Centre, e.g., Medical profile, current immunization records, health and safety training, police check, etc.
•	More information on each teaching centre and CPE supervisors, including telephone numbers, may be found at www.cpe-toronto.ca
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Privacy Policy

The CASC Supervisors of the GTA (CSGTA) are committed to maintaining your trust and confidence. The following privacy policy is designed to protect the personal information you provide on our website. Your right to privacy is fundamental to us.
Our website aims to educate and inform our students, potential students, applicants, and the general public about the programs offered by CSGTA. When you visit this site and access information, you are anonymous. We do not require you to provide personal information to view it.
However, when you apply for one of CSGTA's programs, we ask for detailed information from our applicants. Given the sensitive nature of clinical psychospiritual education, CSGTA is responsible for protecting the students' potential clients by thoroughly reviewing the qualifications, experience, and gifts of each person applying to one of our programs. We will also endeavour to protect the confidentiality of the information applicants provide. Therefore, we will not share this information with anyone not involved in the application approval process.
We will not use the applicant's e-mail or contact information other than contacting the applicant regarding their application status or, after registration, to contact students regarding matters directly related to their participation in CPE programs.