Please complete and sign Application and return it with supporting documentation as attachments to [email protected]. Alternatively, you may also bring it with you to the Practicum you are attending. The application is an MSWord.doc file and you may fill this out by copying what is below and pasting it in a a new document you create.
IMHU Application to Be a Spiritual Emergence Coach (SEC)
PLEASE PRINT CLEARLY if you are not typing.
Check One: Application as a Peer ____ Application as a Licensed Healthcare Provider ____
(Peer designation is for anyone who is not a licensed healthcare provider, e.g. spiritual director, healer, minister, bodyworker, peer counselor, coach, etc.)
Date of Practicum _______________ Location of Practicum_____________Date of Phase One/5 online webinars on Spiritual Emergency________________
Full Legal Name: _________________________________
Mailing Address: _______________________________ _______________________________
Email Address: _________________________________
(Use “Ø” to distinguish from the letter O, capitalize L and I to distinguish from 1.)
Telephone Numbers: Work (_______) _______-___________ ex _______
Home (_______) _______-___________
Cell ( ) ______-___________
Please state your reason for applying to become an SEC.
(Use another page if necessary)
Do you have someone to work with as a co-facilitator?
Name:
Their certification/licensure:
Do you have resources for networking with other supportive people in your location?
Your Licenses:
I hold the following current healthcare or mental health licenses. E.g. License to practice Physician, Psychologist, Psychiatrist, Social Worker, Counselor, Nurse, Coach, etc.
Location: License # Expiration:
Please attach evidence of above. Applications without documentation will not be processed.
Certifications: Year Received:
Certification University or Institution. Please include certification of Peer Specialist, if achieved.
Higher Education:
Degree(s): University or Institution:
Year Received:
Please attach evidence of above. Applications without documentation will not be processed.
Related Experience:
Please describe any personal, professional or educational experience that you feel supports your application to become an IMHU authorized SEC. If more space is needed, please attach a separate sheet.
Publications:
List here or attach a list of titles of any relevant publications.
Do you have a physical or mental condition or addiction to any substance that could impair competent professional performance or jeopardize public health and safety? YES__________ NO__________
Attach an explanation for “YES” responses noting how your condition might impair you if you are facilitating a group as an SEC.
Have you been subject to an investigation or disciplinary action by a health care organization, professional association, governmental entity or regulatory or licensing agency/authority, and/or have you ever been convicted, found, or entered a plea of guilty, or are you presently being investigated or charged with any felony or misdemeanor directly relating to your or public health and safety?
YES__________ NO__________
Attach an explanation for “YES” responses.
Are you currently involved with or do you anticipate being involved in any illegal behaviors in your work with others? If so, please explain. (See IMHU’s Ethical Guidelines)
IMHU provides an online directory which includes IMHU-authorized SEC’s NAME, CITY, STATE, Licensure & contact information. Check here_____ if you DO NOT want to be included in our online directory or listed at IMHU.org as having completed coursework that can lead to becoming an SEC.
Please ask someone, preferably in a field related to group facilitation, who knows you well in a work capacity to write a recommendation for you and ask them to send it to [email protected] directly with clear mention naming you as having applied for SEC status. The recommendation should come from a person who has observed you when you are interacting with a group—not just a personal friend or someone you professionally work with one to one, or a group participant. Please write the name of the person who will send a recommendation: ________________________
The SECs we certify are required to work within the mandates of their own individual licenses, scopes of practice, skills and knowledge regarding sessions of coaching, counseling, and psychotherapy within groups and with individuals, i.e,. one to one. Certification as a SEC does not authorize you to do one to one counseling, or therapy or to act as a counselor or therapist to individuals or groups you facilitate as a SEC. However, we encourage you to organize and hold groups that share experiences and resources about spiritual experiences, spiritual emergence and spiritual emergency.
By signing, you acknowledge and affirm that:
(1) you have carefully read and understand the IMHU Policies, Procedures and Requirements for becoming an IMHU – SEC, and you have read our Ethical Guidelines;
(2) you agree to abide by these terms in these two documents;
(3) you recognize that participation in and or completion of coursework and practicum/workshop does NOT guarantee becoming certified as a SEC now or in the future;
(4) you agree to a background check; and
(5) the information you have provided in this application and in the attached documentation is true and correct to the best of your knowledge.
PRINTED NAME:
LEGAL SIGNATURE:
DATE:
SIGN/SCAN/SEND THIS APPLICATION with supporting documentation to: [email protected]
You may also give it to the person facilitating the Practicum during the Practicum.
Update as of 2024: regarding fees and facilitators for Certification:
Payment in future will be based on the IMHU-authorized Coach’s own fee schedule.
Continuing Education (CE) hour credits are available to MDs, licensed psychologists, MFTs, counselors, social workers and nurses if the particular practicum attended is facilitated by an IMHU representative with appropriate credentials to qualify for giving CEs. Currently, Emma Bragdon, PhD, Executive Director of IMHU, is presenting Phase One and Two and is qualified to offer CE credit.
As our network is expanding, we are in the process of qualifying IMHU-endorsed facilitators in other parts of the world to facilitate the Practicums for both peers and licensed healthcare providers.
We may be in a position to offer scholarships in cases of financial constraint. Please contact us individually if you want to apply for a scholarship: [email protected]
IMHU is grateful to ACISTE.org for use of the template for their application form.
v 5-2-22