New Certification Application

Therapist Certification Association
Certification Application

Submit this completed application along with all required documentation to TCA. Failure to submit all required documentation will result in a delay of your certification. Thank you.

Section I: Identifying Information

Complete the section below as you would like it to appear on certificates, the TCA website, etc. Please update your contact information if it has changed.

A. Personal

Legal Name(*)
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Preferred Name
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Date of Birth(*)
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Email Address(*)
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Cell Phone(*)
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Home Address(*)
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City(*)
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License#(*)
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Other Phone
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State & Zip(*)
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Section I Continue

B. Professional – Primary Office

Agency / Employer Name(*)
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Business Address(*)
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City(*)
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Work Phone(*)
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Website Address(*)
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State & Zip(*)
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Fax
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Section II: Expertise/Specializations

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Section III: Education

Please update your highest level of education obtained (send or upload a copy of your diploma):
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Upload copies of your Diploma/s below. Please note only PDF, JPG, PNG formats max size 5mb

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Please identity all colleges and universities you have attended since your initial certification.

College, University, and/or Certification Program Name
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Accredited or Licensed Institution
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Date Completed
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Section IV

A. Licenses

What professional licenses do you currently hold?
License
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Expiration Date
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Are you currently an intern?
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If Yes, are you working towards obtaining state licensure?
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Have you ever had a license suspended, revoked, or a disciplinary action? If Yes, please explain in the space provided below.
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B. Certifications

What professional certifications do you currently hold? Upload or attach copies of current certifications.
Certification
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Expiration Date
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Have you ever had a license suspended, revoked, or a disciplinary action? If Yes, please explain in the space provided below.
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Section V: Clinical Experience (optional)

Describe how you are using your TCA certification.
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Section VI: Ethics

Have any ethical, legal, or professional proceedings; ethical hearings; or malpractice claims been brought against you? If yes, please describe:
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Section VII: Ethics Statement

1. TCA Therapists and Professionals need to have a working knowledge of the TCA Code of Ethics.
2. Dual relationships that might impair the TCA Therapist’s or Professional’s objectivity and judgment must be avoided, i.e.: family members, friends, etc.
3. TCA Therapists and Professionals will not engage in sexual, physical, or romantic intimacy with clients and/or associated individuals.
4. TCA Therapists and Professionals will not engage in reparative therapy or pathologize homosexuality in the therapeutic setting.
I have read the TCA Code of Ethics. I will abide by the requirements of TCA and the TCA Certification Program as related to applicant certification and generally accepted principles of professionalism, ethics, and practice standards. I hereby declare under penalty of perjury the information included in my application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or evasive answer to any questions may lead to denial of my application or subsequent revocation of my certification on ethical grounds. I will abide by the current laws and rules that govern my practice. I understand that TCA reserves the right to re-classify persons who have taken the courses for certification if laws, ethical regulations, or standards for the behavioral health industry change. I understand that CST, CCS, CHSP, SAC, CTCT, CTCP, CKAT, and CKAP are designations that the practitioner has completed specialty training in the assessment and treatment of the specialty area. These designations do not qualify a person for state licensure.
TCA reserves the right to modify the terms of the Code of Ethics manual at any time and will provide notice to the TCA listserve. The modifications will be effective at the time the email is sent and, by signing below, you signify your agreement on a prospective basis.

Position Statement

TCA is a sex addiction-positive association. This does not mean that our professionals need to treat sex addiction or may not have other viewpoints. It does mean that our professionals will make no derogatory, demeaning, or dismissive statements regarding sex addiction and, if a sex addiction therapist (including IITAP certified therapists) refers a client to a TCA certified therapist, that therapist will work cooperatively with the addictions therapist to facilitate the client’s recovery and help that client develop the ability to have a healthy sexual life, however the client defines it.

By selecting the "I Agree" box below, I certify that all statements made herein are true to the best of my knowledge.

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You have to agree before you can submit this application

Date(*)
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