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This form is intended for first-time applicants for the International Board of Christian Care’s Board of Christian Life Coaching’s Certified Brain Health Coach Credential.

Demographic Information

Name(Required)

First Last

Address(Required)

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

Please provide the name of the Church or ministry where you provide coaching.

Example: Abundant Life Coaching or Temple Church

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 Light University’s Brain Health Coaching Certification Program.

Gender(Required)

Male

Female

Age(Required)

Ethnicity(Required)

Credential Designation

I am applying for the following credential:

Credential(Required)

CBHC – Certified Brain Health Coach (36 hours of education/training required)

Note:

Education/training must include completion of the Certified Brain Health Coach Program offered by Light University.

Professional/Formal Education and Training

CBHC – Certified Brain Health(Required)

The Certified Brain Health Coach credential requires a minimum of 36 hours of education/training required in Christian Life Coaching.

Yes (I meet the requirements)

No (I do not meet the requirements)

Verifying Documentation(Required)

I have appropriate documentation (Certificates of Completion) verifying my education/training through Light University’s Brain Health Coaching Program.

Yes

Education/Training Files(Required)

Drop files here or

Accepted file types: png, jpg, pdf, heic, Max. file size: 250 MB.

Please upload copies of the certificates of completion for the “Brain Health Coaching”, “Change Your Brain, Change Your Life”, and “Brain Warrior’s Way” courses.

Practice Information

Do You Charge A Fee For Your Coaching Services?(Required)

Yes

What is your fee range?

(e.g. $325.50 – $755.50)

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, 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 CBHC 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 BCLC Continuing Education Guidelines.

CE Renewal Statement(Required)

Yes

I understand that any Board of Christian Life Coaching credential is a voluntary National Credential and does not offer any state or national licenses.

BCLC credentials are 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 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 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 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)

Example: John Smith, MBA

Affirm and Attest(Required)

I affirm and attest by my signature below that I have answered all questions in this Application truthfully and have done so to the best of my knowledge and with full disclosure. I further authorize the AACC and/or the IBCC to verify this information and understand that in the process of verification, these facts might become known to third parties. I expressively waive any claim to confidentiality of the material enclosed in this Application except where otherwise noted.

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)

MM slash DD slash YYYY

Brain Health Coaching Application

Certified Brain Health Coach