International Certificate of Core Competency in Reflective Practice & Supervision Application

International Certificate of Core Competency in Reflective Practice & Supervision Application

First Name*

Middle Initial

Last Name*

Email Address*

Phone Number*

Mailing Address*

Address where certificate will be mailed.

State*

Profession*

Early Childhood Experience*

How many years have you worked in the field of early childhood (Birth to five)?

Other Endorsements or Credentials*

Have you been endorsed in any Infant Early Childhood Mental Health system? If so, please specify the endorsement you hold and from which Infant Mental Health Endorsement system.

Reflective Supervision Provision*

Do you currently provide Reflective Supervision for people providing direct services perinatal to children aged 5 and their families?

Yes

Degree*

Do you have a degree in mental health, child development or a related feld?

Yes

Documentation to be Uploaded

1. LEARNING AND KNOWLEDGE OUTLINE: Highlight the training and workshops attended or taught related to reflective practice and supervision. This must include a minimum of 12 hours directly related to reflective practice and supervision provision. 2. PERSPECTIVES ON REFLECTIVE PRACTICE AND SUPERVISION: Reflections on reflective practice and supervision that should answer the questions: - Why is reflective practice and supervision important to the field? - How has reflective practice and supervision contributed to your professional growth? - How do you anticipate that the reflective practice and supervision which you provide will contribute to the professional growth of others? 3. CURRICULUM VITAE/ RESUME that demonstrates knowledge and direct services to children and families. 4. DIPLOMA, DEGREE AND/OR LICENSE for field of practice in which the candidate is providing reflective supervision. 5. LETTER OF RECOMMENDATION from a supervisor who mentored/trained and supported the candidate's reflective practice and supervision with others.

FIles Upload*

Please upload the five documents described above. Each document should be uploaded with the Applicant’s name and the document type (e.g., R. Martinez-Resume)

Drag and drop files here or

Reflective Supervision*

I have received at least 12 hours of reflective support and feedback on my own provision of reflective practice and supervision to others.

Yes

Attestment*

I attest that all the information I have provided in this National Certificate for International Certificate of Core Competency in Reflective Practice and Supervision application is true.

Yes

Service Delivery System*

I attest that I have prior knowledge of the service delivery system (e.g., Early Intervention, Head Start) in which I provide Reflective Practice / Supervision.

Yes

Scope of Practice*

I attest that I provide Reflective Practice / Supervision only within my professional scope of practice.

Yes

Application Fee

$350 Application Fee Payment Required, payable to WestEd. Please note that your application for the International Certificate of Core Competency in Reflective Practice & Supervision will be reviewed once the application fee is received. Mail the application fee check to:

WestEd

ATTN: California Center for IFECMH, IC3RPS

1000 G Street, 5th Floor

Sacramento, CA 95814

Reflective Supervision Verification

After submitting your IC3 RPS application, your will receive a survey link. Email this survey link to three contacts you have selected to verify the reflective practice supervision you provided to them. The survey responses will be returned directly to the California Center.

Send me a copy of my responses

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