You can fill out an application online, or mail a paper version along with your Letter of Reference.

Application Form: Letter of Reference:
Instructions for submitting a CPE Application Form online:
  1. Click here to fill out the form.
  2. Fill out the form as completely as possible.
  3. Click on the "Send" button to send the form to Pastoral Services.
  4. You will be contacted by a Pastoral Services staff member within 3 business days 
  5. NOTE: You must still print out and mail the Letter of Reference when filling out an online application form.
Instructions for Printing and Mailing a CPE Application Form and/or Letter of Reference:
  1. You can download the form in MS Word format and fill it out using your word processor, or download/print the form in PDF format, and fill it out by hand.
  2. Download and print the Letter of Reference.
  3. Fill out the application/letter as completely as possible.  Attach additional pages and information as necessary.
  4. Mail the Application and the Letter of Reference to:
        Pastoral Services Department
        Hartford Hospital
        80 Seymour Street
        P.O. Box 5037
        Hartford, CT 06102-5037
  5. You will be contacted by a Pastoral Services staff member within 3 business days.

(Please fill out the form as completely as possible... items marked with an asterix (*) are required.)


* Application For: Extended Unit   Residency   Summer   SIT
(Please note that Residency and SIT program require an In-person interview in their admissions process)

Contact Infromation:
Earliest Date You Can Begin:
* Name:
* Present Mailing Address:
  City: State: Zip:
Permanent Mailing Address:
  City: State: Zip:
* Telephone:
E-Mail Address:
Denomination/Faith Group Affiliation:
Association, Conference,
Diocese, Presbytery, Synod:
Jurisdictional Authority:
(Name/Title)
Local Church & Ministry Position:
Present Position:
* Ordained?   YesNo    If Yes, Date:   
* Licensed?   YesNo    If Yes, Date:   
* Appointed?   YesNo    If Yes, Date:   

 Education:
  Degree:
College: Yes  No
Seminary: Yes  No
Graduate: Yes  No
Previous Clinical Pastoral Education:
(Please include location, date and name of supervisor for each instance)

References and Addresses:
Denomination/Faith Group:  
Address:
Academic:
Address:
Other:
Address:

Other Information:

1:
 
Please give 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, your current family relationships and important and supportive social relationships.

2:
 
Please describe 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.
 

3:
 
Please describe 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.)

4:
 
Please provide an account of an incident in which you were called to help someone.
 
Include the nature 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 send 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 and CPE, but it was more than two years ago, include feedback from current pastoral colleagues and/or administrative supervisor.

5:
 
Please describe your impression of CPE and your educational goals.
 
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 the 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.

6:
 
Please describe any special needs.
 
Example health, financial, housing, transportation, etc.


7:
 
Address:
An admissions interview by an ACPE Supervisor or other qualified person.
 
You are required to complete an admission interview with an ACPE supervisor or a person approved by the center to which you are applying. Contact a local CPE center if you need help in locating an interviewer in your area.

Those with Previous CPE Should Complete the Following:

8:
 
Copies of previous CPE evaluations written by you and your supervisor.

9:
 
What was the most significant learning experience in previous CPE?
 
Show how you have continued to work in this learning method, and illustrate your strengths and weaknesses as a professional person.

10:
 
Personal Goals
 
Include personal and professional goals and how continued training will aid that process.


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