Application for Membership and Change of Membership Status

Cheques should be made payable to CGPA.
MEMBERSHIP DUES are payable after notification of acceptance. PROCESSING FEE $20.00

Part I

Title of address:
Last Name:
First Name:
Mailing Address:
City:
Province/State:
Postal Code:
Home Telephone:
Work Telephone:
Fax:
Your Highest degree:
What membership are you applying for?
Today's Date:

DD/MM/YY


Part II

A. Professional Education

Institution

Dates Attended

Degree Obtained and Year Granted

1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.

B. Professional Licensing Credentials

Please choose your discipline and complete the details of
Provincial/State certification together with the appropriate numbers:

PSYCHIATRY PSYCHOLOGY SOCIAL WORK NURSING
OCCUPATIONAL THERAPY OTHER (SPECIFY)

Other: Please give details:

Province/State License/Certification No.


NOTE: If you checked "OTHER" in Part II B, please comply with the following:
Write an explanatory letter detailing your current group work, activities, settings,
supervision, supervisor, and professional organization of which you are a member



Part III

Indicate what type of supervision you have received

A) Group Psychotherapy

No. of
Group
Sessions

Supervisor

Supervisor's Professional
or
Academic Affiliation

Inclusive Dates
From/To

Hours
per Week

Total
Hours

1. 1. 1. 1. 1. 1.
2. 2. 2. 2. 2. 2.
3. 3. 3. 3. 3. 3.
4. 4. 4. 4. 4. 4.

B) Individual Psychotherapy you have done

No. of
Cases

Supervisor

Supervisor's Professional or
Academic Affiliation

Inclusive Dates
From/To

Format of
Supervision
(1-3)

Total
Hours

1. 1. 1. 1. 1. 1.
2. 2. 2. 2. 2. 2.
3. 3. 3. 3. 3. 3.
4. 4. 4. 4. 4. 4.


Part IV

PERSONAL GROUP EXPERIENCE: TYPE OF EXPERIENCE CODE: 1) Experiential Training 2) Therapy

Type of
Experience

Total Hours

Inclusive Dates
From/To

Leader/Therapist

Location/Conference

1. 1. 1. 1. 1.
2. 2. 2. 2. 2.
3. 3. 3. 3. 3.
4. 4. 4. 4. 4.


Part V

Two reference letters are required

1.
Name Address Telephone
2.
Name Address Telephone

For full membership, both referees must be qualified group psychotherapy supervisors. For Associate membership, one of the referees must be a qualified group psychotherapy supervisor. A qualified group psychotherapy supervisor is a full member of CGPA or AGPA or is eligible for such membership, and has three full years beyond full membership criteria. A referee must be knowledgeable of your ethical character, professional qualifications, and training in group psychotherapy. Any exceptions to the qualifications of a referee must be explained in a cover letter from the applicant and will require approval by the membership committee.

To avoid delay we recommend that you obtain each of your reference letters in a sealed envelope with your referee's signature across the seal and enclose them with your application. If this is not possible, it is your responsibility to make sure that your referees send their letters directly to head office. It is policy of the association to keep all letters of reference confidential.

Your application will not be processed until we receive your completed membership form, the two letters of reference, and the $20.00 processing fee.