CiiAT - The Canadian International Institute of Art Therapy
The Proulx Global Education & Community Foundation
143 Joseph Street, Victoria BC, Canada, V8S 3H6
Phone: 1-866-452-4428
Email:  [email protected] — [email protected]
Web: ciiat.org — proulxfoundation.org

Application for Private Practice Approval as Clinical Placement

This application aims to determine the suitability of private practice settings to become clinical placement sites for APD students. The student must provide documentation for the Clinical team and the Clinical Competencies Committee to assess these sites. The clinical team and committee review their suitability to support APD students in an ethically and legally safe and rigorous learning environment in alignment with our Institute’s principles and policies. No fee is required. However, we encourage students to give 4-6 weeks of processing time.

Student Information:

APD Student name:

Student email:         DCCH Completed to Date:

List other clinical placement sites in progress or completed:

Private Practice Information:

Name of Private Practice:

Legal Business Name (if different):

Business Registration Number:

Private Practice Website:

Business Postal Address:

Private Practice Location:

Location where Student’s clients would be served?

Physical Address of Site where the student will be practising:

Which online conferencing platform?

Name of the PIPEDA/HIPPA compliant online conferencing platform (if specified):

Tell us more about the conferencing system you're using (if specified):

Lead Psychotherapist Information:

Name of Business Owner or Lead Psychotherapist:

Email:         Phone:

Credentials of Business Owner or Lead Psychotherapist:

Site Supervisor Information (if specified):

Name of Site Supervisor:

Email:         Phone:

Credentials of Site Supervisor:

Site Information:

Description of client population served at this practice and by the student:

Will clients be paying fees for your art psychotherapy services at this site?

The referral process and how the student receives remuneration:

All the information I provided is accurate, complete, and truthful.

I agree to the CiiAT privacy policy listed at https://ciiat.org/privacy-policy/

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Application for Private Practice Approval as Clinical Placement

Unique Document ID: 72e7785a1f5a0a639c99db26276eb6458799d042

Build. Track. Sign Contracts.

Timestamp	Audit
2024-04-15 5:02 pm PDT	Application for Private Practice Approval as Clinical Placement Uploaded by Behan Webster - [email protected] IP 216.232.132.129
2024-04-15 5:59 pm PDT	Document owner [email protected] has handed over this document to [email protected] 2024-04-15 17:59:16 - 216.232.132.129
2024-04-15 5:59 pm PDT	CiiAT Practicum - [email protected] added by Michelle Winkel - [email protected] as a CC'd Recipient Ip: 216.232.132.129

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://ciiat.org/

Audit Trail Serial# bbf994b8e578877cbe518adac8ddcf54