Hope Certificate Application

Dear Hope Certificate Applicant,

I’m glad you’ve decided to pursue becoming a certified Hope focused couples therapist. We at the Charis Institute/ Ripley Consulting are dedicated to supporting pastoral care providers, clinicians and students in training to become excellent couples therapists using the Hope approach. If you are seeking this certificate you are demonstrating your dedication to providing outstanding assistance to couples in your community. This certificate will distinguish you in your community as qualified in the use of the Hope approach to couples counseling.

Steps to becoming a Certified Hope Therapist

To qualify a therapist or pastoral care provider must:

Either be a matriculating graduate student or hold at least a master’s degree in a mental health or pastoral care program,
or be licensed in a mental health professional,
or an ordained minister.

There are several “classifications” of certificate in keeping with ethical scope of practice: student, pastoral counselor or licensed therapist.

To obtain a certificate you will engage in a full process of learning and demonstrate your learning. You will:

1. Read the textbook “Couples Therapy: A Hope Focused Approach” by Jennifer Ripley and Everett L. Worthington, Jr. published by Intervarsity Press
2. Watch the accompanying video training with lecture and demonstrations of Hope couples counseling found on the website, www.hopecouples.com
3. Take the Hope certification test- both multiple choice and open ended questions, passing at 90% is required.
4. Create a demonstration 60-90 minute audio or video with a mock couple (role play) using the Hope treatment approach and submit for feedback.
5. Submit a case intake report using the Hope focused approach as described in the textbook and website (templates on the website)

Many blessings as you seek this certificate.

Question Title

* 1. Which type of certificate are you seeking?

Student ($99)

Pastoral ($129)

Professional ($149)

Question Title

* 2. Contact Information

Name:

Address:

Phone:

Email:

Question Title

* 3. For student/resident applicants, please take a picture of your student ID and upload it here. If you are a pastor, please take a picture of your ordination certificate or other qualifying document for pastoral care. If you are a professional mental health provider, please upload a picture of your license.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 4. Professional Ethics Disclosure Information

	Yes	No
Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other professional (mental health or clergy) education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?	Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other professional (mental health or clergy) education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? Yes	Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other professional (mental health or clergy) education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? No
Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?	Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes	Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? No
Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct?	Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct? Yes	Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct? No
Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?	Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? Yes	Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony? No
In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, duties as a mental health care professional or pastoral care, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?	In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, duties as a mental health care professional or pastoral care, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? Yes	In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, duties as a mental health care professional or pastoral care, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? No
Do you use any chemical substances that would in any way impair or limit your ability to practice your profession and perform the functions of your job with reasonable skill and safety?	Do you use any chemical substances that would in any way impair or limit your ability to practice your profession and perform the functions of your job with reasonable skill and safety? Yes	Do you use any chemical substances that would in any way impair or limit your ability to practice your profession and perform the functions of your job with reasonable skill and safety? No

Question Title

* 5. Professional Ethics Questions

	Yes	No	I am a student, never licensed or ordained
Has your license, ordination, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or ordination or certification board?	Has your license, ordination, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or ordination or certification board? Yes	Has your license, ordination, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or ordination or certification board? No	Has your license, ordination, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or ordination or certification board? I am a student, never licensed or ordained
Has there been any challenge to your licensure, ordination, registration or certification?	Has there been any challenge to your licensure, ordination, registration or certification? Yes	Has there been any challenge to your licensure, ordination, registration or certification? No	Has there been any challenge to your licensure, ordination, registration or certification? I am a student, never licensed or ordained
Have you voluntarily or involuntarily surrendered your license or ordination, limited your privileges or not reapplied for privileges while under investigation?	Have you voluntarily or involuntarily surrendered your license or ordination, limited your privileges or not reapplied for privileges while under investigation? Yes	Have you voluntarily or involuntarily surrendered your license or ordination, limited your privileges or not reapplied for privileges while under investigation? No	Have you voluntarily or involuntarily surrendered your license or ordination, limited your privileges or not reapplied for privileges while under investigation? I am a student, never licensed or ordained
Have any of your board certifications, ordination or eligibility ever been revoked?	Have any of your board certifications, ordination or eligibility ever been revoked? Yes	Have any of your board certifications, ordination or eligibility ever been revoked? No	Have any of your board certifications, ordination or eligibility ever been revoked? I am a student, never licensed or ordained
Are you currently the subject of an investigation by any church officials (if minister), hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?	Are you currently the subject of an investigation by any church officials (if minister), hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? Yes	Are you currently the subject of an investigation by any church officials (if minister), hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? No	Are you currently the subject of an investigation by any church officials (if minister), hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? I am a student, never licensed or ordained
Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?	Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? Yes	Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? No	Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? I am a student, never licensed or ordained
Have you ever been court-martialed for actions related to your duties as a medical professional or clergy member?	Have you ever been court-martialed for actions related to your duties as a medical professional or clergy member? Yes	Have you ever been court-martialed for actions related to your duties as a medical professional or clergy member? No	Have you ever been court-martialed for actions related to your duties as a medical professional or clergy member? I am a student, never licensed or ordained

Question Title

* 6. I attest that all of the above information is accurate. If I answered yes to any of the above questions, I will email an explanation to Dr. Ripley at jennrip@mail.regent.edu for review to determine if pursuit of the certificate is acceptable. Please write in your name here as equivalent to a signature.

Question Title

* 7. This training is self-paced, allowing you to work at your own speed and timing. However, we have found that focusing the learning on the coming three months is typically a target date beyond which applicants have a hard time finishing the training. You can finish the training on a longer timeline but we do have a limit of one year before we request applicants start over with the application process. To help you, what is your personal deadline of when you would LIKE to have completed all of the steps for the training?

Date

Question Title

* 8. Great! You have registered. Our staff will send an invoice through Ripley Consulting / Dr Ripley to your email address for payment.

You can move forward on reading the book "Couple Therapy: A Hope Focused Approach" by Ripley & Worthington and watching the videos at our website, https://www.hopecouples.com/video-training-series. Return to the website, or email us, when you are completed those and are ready to take the multiple choice and essay tests.

I understand.