Phase 2 Contact Details – Association of Certified Biblical Counselors

Contact Details

Please complete each step of this form. You may save it and return at a later time to provide more information.

Prefix

First Name

Last Name

Street Address

Street Address 2

City

Country

State

Postal Code

Email

Phone

U.S. Citizen

Preferred Language

Birth Date

Gender

Female

Male

Marital Status

Name of Spouse

If applicable

Current Employment

Position

I have reviewed and updated my contact details above.

Education

College

Major/Degree

Graduation Year

Theological degree?

Yes No

Seminary

Major/Degree

Graduation Year

Other education, training, agencies, or organizations which you have attended or belong to

Church Information

Are you ordained by a local church body?

Yes No

Ordination Certificate

If yes, who was the ordaining local church? Please also list city/state location.

List Pastoral Experiences (dates/locations)

Current Church Name

Are you a member?

Yes No

If yes, how long?

Denomination or religious groups church is associated with

Other affiliations not listed above

Church Address

Street Address

Address Line 2

City

Country

State/Province/Region

Postal Code

Church Phone

Church Website

Pastor’s First Name

Pastor’s Last Name

Pastor’s Email

Short Answer Questions

Summarize your approach to counseling

State your view of lay counseling

In 5 to 10 sentences, explain your conversion to Christ, including a description of your life before and since.

What are your reasons for desiring certification membership with ACBC?

Have you ever applied to be a certified counselor with ACBC before? If yes, when and why was it not completed?

Name of church under whose authority you currently counsel?

Are you involved in any sinful conduct or do you have unresolved conflicts, which, if known, would cause others to question the appropriateness of your being a certified biblical counselor? If yes, please explain.

Have you ever been placed under church discipline? If yes, what was the outcome?

Are you listed in the Public Sex Offender Registry? If yes, please explain

Have you ever been convicted of a felony? If yes, please describe the nature of the conviction, include the date, and explain which state or federal regulations apply to you and which ones you are complying with

If you have been convicted with a felony, please answer the following questions: Is the church or ministry whose authority you counsel under aware of this felony? Are there protections in place to prevent a scandal if and when questions are raised about this?