Step 1 of 3

This form is intended for first-time applicants for the International Board of Christian Care’s Board of Mental Health Coaching.

Demographic Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Practice/Org/Church where you provide Mental Health coaching services

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Cell Phone(Required)

Email(Required)

*Email used when registering for MHC course.

Gender(Required)

Male

Female

Age(Required)

Ethnicity(Required)

Attestation

Note: The following statements require your attestation (affirming each one to be true to the best of your knowledge). Please be sure to respond to each and every section regarding yourself and your counseling/caregiving practice or ministry

I have read the AACC Doctrinal Statement, ethical integrity, legal history, Mental Health Coach and ( 2023 AACC Code of Ethics)and am in 100% compliance with all requirements and statements of fact outlined in this document:

AACC Doctrinal Statement(Required)

Yes

I understand that in order to renew and maintain my BMHC credential, I must complete a minimum of twelve (12) contact hours of approved Continuing Education every two years and that these hours must incorporate biblical principles and life coaching skills with theory, knowledge and practice. I further acknowledge I have read and understand the BMHC Continuing Education Guidelines:

I understand that a BMHC credential is a voluntary National Credential and does not offer any state or national licenses.

BMHC credential is a voluntary(Required)

Yes

Preferred Name with Credentials

In the space below, list how you would like your name and credentials to appear (including appropriate punctuation) on the BMHC Credential Certificate. Any degree listed must represent an earned degree from a regionally accredited institution of higher learning (not a degree in process or honorary degree), and any state/regulated licenses or professional credentials listed must have already been earned/received. Do not include the BMHC credential you are applying for. Academic degrees are listed first (usually only one from any particular discipline), followed by licenses and other certifications. Please do not use more than three sets of letters after your name. I affirm and attest that my name and the credentials given on the line below are printed exactly as I desire for them to appear on my BMHC Credential Certificate and further reflect a true and accurate portrayal (as described above) of my valid professional education, training, licensure, and/or certification:

Please Print Name and Credentials Clearly(Required)

Affirm and Attest(Required)

Yes

Applicant Signature(Required)

First Last

Coach hereby indemnifies and agrees to defend and hold harmless AACC and its affiliates, subsidiaries, officers, employees and directors, from and against any and all demands, claims, actions, proceedings, damages, liabilities, losses, fees, costs or expenses (including, without limitation, reasonable attorneys’ fees and the costs of any investigation) directly or indirectly arising from its own acts or omissions. I affirm and attest by my signature below that I have answered all the questions in this application truthfully and with full disclosure.

Date(Required)

BMHCA

Board of Mental Health Coaching Application Form

This form is intended for first-time applicants for the International Board of Christian Care’s Board of Mental Health Coaching.

Demographic Information

Credential Designation

Note:

Professional/Formal Education and Training

Attestation

Preferred Name with Credentials