(Accredited CPE Center name)
Department of Pastoral Care and Education
Agreement for Hospital Affiliate
I.
This agreement is made between the (accredited center for Clinical Pastoral Education by
the Association for Clinical Pastoral Education, Inc.) and:
__________________________________at______________________________
(Congregation)
(City/State)
for the purpose of linking the pastoral setting as an affiliate learning site to the CPE
program at (accredited CPE center).
II.
The Intern _____________________ shall participate in an extended unit of Clinical
Pastoral Education beginning Month, Day, Year and ending Month, Day, Year. Under
this agreement the Intern will:
A.
B.
Participate in the Hospital-based education and pastoral activities.
Participate in clinical learning opportunities at the affiliated learning site. The
Intern’s ministry is subject to supervision by the CPE Supervisor, as arranged by
the Supervisor and Intern.
The Clinical Pastoral Education program at (accredited CPE center) will provide supervision of
the Intern’s ministry and learning within the bounds of the program, as stated above, in both
Hospital and congregational settings. Supervision will be provided by regular individual
conferences with the Intern, group conference with a peer group of Interns, written materials
submitted by the Intern, and observation of the Intern’s ministry. The Supervisor-Intern
relationship will maintain the confidentiality of the Intern’s ministry in the Hospital and pastoral
setting.
(accredited CPE center)
Dept. of Pastoral Care and Education
Address
City, State, Zip code
____________________________________
____________________________________
____________________________________
(Name and Address of Congregation)
_________________________________
CPE Supervisor
Dept. of Pastoral Care and Education
Phone Number
____________________________________
(Administrative Liaison of Congregation)
____________________________________
(Date)
________________________________
Administrator the program reports to
(accredited CPE center)
Phone Number