Application for Clinical Pastoral Education

Spiritual Care Services

Fields marked with * are required!

* This application is for:


Sutter Medical Center, Sacramento
John Grindler Katonah, M. Div., ACPE
CPE Education Coordinator
Spiritual Care Services
2800 L Street
Sacramento, CA 95816-5600
(916) 733-9671 | katonaj@sutterhealth.org


(begins June)

or

Summer Fall Winter Spring


Gerald Jones, M.A., BCC
Director of Chaplain Services
One Medical Plaza
Roseville, CA 95661
(916) 781-1147 | jonesg@sutterhealth.org




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Personal Information

* U.S. Citizen? YES    NO

Education

Previous Clinical Pastoral Education

Include former student/supervisor evaluations.
Upload your own file or mail hardcopy:

References & Addresses

Please respond to each of the following items. Fields marked with * are required.
All Yes/No boxes must be checked

Insert your own file with the answers to the following questions in the browse section below:

  • A reasonably full account of your life.  Include, for example, significant and important persons and events, especially as they have impacted, or continue to impact, your personal growth and development.  Describe your family of origin, current family relationships, and important and supportive social relationships.
  • A description of your spiritual growth and development.  Include, for example, the faith heritage into which you were born and describe and explain any subsequent, personal conversions, your call to ministry, religious experiences, and significant persons and events that have impacted, or continue to impact, your spiritual growth and development.
  • A description of your work (vocational) history.  Include a chronological list of jobs/positions/dates of employment and a brief statement about your current employment and work relationships.
  • An account of a “helping incident” in which you were the person who provided the help. Include the nature and extent of the request, your assessment of the issue(s), problem(s), and situation(s).  Describe how you came to be involved and what you did.  Give a brief, evaluative commentary on what you did and how you believe you were able to help.  If you have had prior and recent CPE, please attach a copy of a recent verbatim as your ‘helping incident’ and add to the verbatim your own notes on how and what you learned from sharing this verbatim with your supervisor and/or peers.  If you have had CPE, but it was more than two years ago, include a recent account of a helping incident, written up in a verbatim format.  If possible, include feedback from current pastoral colleagues and/or administrative supervisor.
  • Your impressions of Clinical Pastoral Education.  Indicate, for example, what you believe or imagine CPE to be.  Indicate if CPE is being required of you.  Indicate any learning goals or issues of which you are aware and would like to address in CPE.  Finally, indicate how CPE may be able to help you meet needs generated by your ministry or call to ministry.  If you have had prior CPE, please indicate the most significant learning experience you had during CPE.  State how you have continued to use the clinical method since your previous experience.  Indicate strengths and weaknesses that you have as they relate to your ministry and your identity as a professional person.  Indicate any personal and/or professional learning goals and issues that you have at this time and how you believe that CPE will help you to attain or address these learning goals and issues.

 

Have you ever been convicted or pled nolo to a misdemeanor, a felony, or other crime? YES    NO

 

  1. Retain your own copy of this completed application and bring it with you to any interview for CPE along with a $25.00 interview fee. PLEASE NOTE:  CPE programs require an admission interview.  Qualified applicants will be contacted by the center regarding an admission interview.

    If you are an international applicant, and have been accepted into our program you will have to obtain appropriate documentation from U.S. Immigration, which usually implies a visa and a U.S. Social Security Number.  Therefore, international applicants should have such documentation approved at least six (6) months prior to the start of the program to which they are applying.  If accepted into the program, can you submit verification of your legal right to work in the U.S.? YES    NO
  • Those who have completed CPE units should insert all previous self and supervisory evaluations.

 

If you are not being interviewed at the Sutter CPE Center, you will need to obtain a written admission interview summary prepared by an ACPE supervisor or another person satisfactory to the Sutter CPE Center.

  1. I certify that all information in this application is factually true, complete, and honestly presented.  I understand that I may be subject to disciplinary action, including admission revocation or program expulsion, should the information I’ve certified be false.  I herby give permission to the ACPE center to which I am applying to access my CPE evaluations and contact previous supervisory personnel about matters pertaining to this current application, and I consent for those contacted to provide the information sought.

    • I verify by sending in this application electronically it constitutes my electronic signature.
      YES    NO         

     

    Signature:          Date:

 

Accredited by the Assocation for Clinical Pastoral Education
1549 Clairmont Road, Suite 103
Decatur, Georgia 30033
404.320.1472
www.acpe.edu