Vermont Board of Allied Mental Health Practitioners Disclosure Requirement Non-licensed and Non-certified Psychotherapists

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1 Vermont Board of Allied Mental Health Practitioners Disclosure Requirement Non-licensed and Non-certified Psychotherapists Vermont law requires that persons placed on the roster of Non-licensed and Noncertified Psychotherapists to disclose to each client his or her professional qualifications and experience, those actions that constitute unprofessional conduct, and the method for filing a complaint or making a consumer inquiry. This must be done by the third visit. Jonathan Patrick Gilmore, M.S., C.A.S. Formal Education: Disclosure of Professional Qualifications and Experience College of St. Joseph 8/01 5/06 Rutland, Vermont Master of Science - Clinical Psychology University of Vermont 8/93-5/94 Burlington, Vermont Certificate of Advanced Study Secondary Education University of Wisconsin 8/84-12/88 Madison, Wisconsin Bachelor of Arts Degree - History and Political Science Training and Continuing Education: See attached pages Psychotherapeutic Practice Experience: Title: Clinician Description of Practice: Outpatient Individual and group psychotherapy to adults, children and families. Administer and interpret psychological assessments and neuropsychological assessments in consultation with supervisor. Provide community based psychoeducation. Full-time paid position. Maple Leaf Clinic 167 North Main St. Wallingford, VT Dates of Practice: 5/07/07 - current Supervisor: Dean J.M. Mooney, Ph.D., NCSP Licensed Clinical Psychologist- Doctorate Licensed School Psychologist - Vermont Nationally Certified School Psychologist

2 Title: Supervising Clinician Description of Practice: Supervise Continuous treatment team for Community Mental Health Agency in the CRT Population with clients diagnosed with severe and persistent mental illness. Provide diagnostic clinical assessment, individual and group psychotherapy, psychoeducation, treatment planning and advocacy for clients and their families. Supervise aspects of CRT program development. Full time paid position. Also completed requirements for educational clinical internship. Community Rehabilitation and Treatment Program Black River Rehabilitation Center HCRS 197 Union Street Springfield, VT Dates of Practice: 1/01/06 5/04/07 Supervisors: Theodore Robbins, MD (1/06-5/07) Licensed Psychiatrist MD Robert Smolinski, M.S., C.A.S. (1/01/06-9/30/06) Licensed Psychologist - Master Dr. Craig Knapp, Ph.D. (1/8/06 5/4/06) Chairman Division of Psychology and Human Services College of St. Joseph Rutland, VT Licensed Clinical Psychologist- Doctorate Licensed School Psychologist - Vermont Title: Clinician Description of Practice: Provide diagnostic clinical assessment, individual and group psychotherapy, psychoeducation, treatment planning and advocacy for clients with severe and persistent mental illness and their families. Participate in CRT program development. Full-time paid staff position. Also met requirements for educational clinical internship. Community Rehabilitation and Treatment Program Black River Rehabilitation Center HCRS 197 Union Street Springfield, VT Dates of Practice: 8/16/03 12/31/05 Supervisors: Theodore Robbins, MD (8/16/03-12/31/05) Licensed Psychiatrist MD Robert Smolinski, M.S., C.A.S. (9/01/05-12/31/05) Licensed Psychologist - Master Dr. Craig Knapp, Ph.D. (1/8/06 5/4/06) Chairman Division of Psychology and Human Services College of St. Joseph Rutland, VT Licensed Clinical Psychologist- Doctorate Licensed School Psychologist Vermont Phillip Shape, M.A., LCMHC (8/16/03-12/31/05) Title: Counselor/ Teacher Description of Practice: Provide counseling and education for adjudicated and referred adolescents in a wilderness education program. Counseling applies principles of Reality Therapy, Experiential therapy, and Therapeutic Crisis Intervention. Full-time paid position. Camp E-Kel-Etu - Eckerd Youth Alternatives NE 13 th Street

3 Silver Springs, FL Dates of Practice: 12/05/94-12/23/96 Supervisors: Scope of Practice: Therapeutic Orientation: Integrated Approach that combines Developmental, Experiential and Behavioral theories and techniques. Client centered. Specialization: Treatment of clients with high suicide risk Treatment for individuals with complex personality disorders Treatment for clients with complex PTSD and developmental trauma Treatment for clients with co-occurring disorders (dual diagnosis) * Methods: DBT and modified DBT approaches. Behavioral and Experiential techniques, including CBT. Client centered, collaborative. *Note: I am not certified or licensed as a Drug and Alcohol Counselor Information Concerning Unprofessional Conduct for the Profession is found below. CLIENT S DISCLOSURE CONFIRMATION My signature acknowledges that I have been given the professional qualifications and experience of Jonathan Patrick Gilmore, a list of actions that constitutes unprofessional conduct according to Vermont Statutes, and the method for making a consumer inquiry or filing a complaint with the Office of Professional Regulation. Client Signature Date Practitioner s Signature Date

4 Jonathan Patrick Gilmore Disclosure Requirement Training and Continuing Education: 8/27-8/29, 2008 The Halstead-Reitan Neuropsychological Test Battery: Comprehensive Clinical Interpretation of Adult Cases The Neuropsychology Center 9400 North Central Expressway, Suite 904 Dallas, TX Jim Hom, Ph.D. & Janice Nici, Ph.D. Advanced training in the clinical interpretation of the Halstead-Reitan Neuropsychological Test Battery in adult cases Advanced Interpretation of Child Clinical Cases July 23-25, 2009 Practical Strategies, Interventions and Treatments for Childhood Developmental Disorders September, 2007 Rutland, Vermont David Meichenbaum, Ph.D. Training in the etiology, clinical assessment, and development of therapeutic treatment interventions for children with Pervasive Developmental Disorders 4/19 4/21/07 The Halstead-Reitan Neuropsychological Test Battery: Administration and Interpretation The Neuropsychology Center 9400 North Central Expressway, Suite 904 Dallas, TX Jim Hom, Ph.D. & Janice Nici, Ph.D. Training in the empirical basis and administration of the Halstead-Reitan Neuropsychological Test Battery

5 Treating Multiply Disordered Suicidal Patients October 16-17, 2006 Northampton, MA Marsha Linehan, Ph.D., ABBP Behavioral Tech, LLC 4556 University Way NE, Suite 200 Training in suicide risk assessment and psychotherapeutic intervention, including standards of care, for suicidal patients. DMHS QMHP Legal Training August 10, 2006 The Retreat Brattleboro, VT Vermont Division of Mental Health 108 Cherry Street, PO Box 70 Burlington, VT Training in Vermont Mental Health Statutes and procedures for involuntary psychiatric admissions Frontiers in the Treatment of Post Traumatic Stress Disorder June day training The Retreat Brattleboro, VT Bessel A. van der Kolk, MD Dept. of Psychiatry, Harvard Medical School, Boston, MA HRI Trauma Center, Brookline, MA Introduction to the neuropsychiatric etiology and treatment of PTSD and Developmental Trauma Intensive Training in Dialectical Behavior Therapy Feb. 28, 2004 March 1,7,8,14,15,21,22,28,29, 2004 April 5,6,12,13,19,20, Bellows Falls, VT The Windham Center Mary Buttitta, MS, LCMHC & Ann Jerman, MA Behavioral Tech, LLC 4556 University Way NE, Suite 200 Intensive 8 day training in theory and practice of Dialectical Behavior Therapy, including Skills training and individual psychotherapy DBT Certification

6 CCISC Training February, day training Montpelier, VT Kenneth Minkoff, MD and Christie Cline, MD Consultants for Vermont Division of Mental Health 108 Cherry Street, PO Box 70 Burlington, VT *Integrating the diagnosis and treatment of substance abuse for clients with severe and persistent mental illness in Community Mental Health Individual Psychotherapy in DBT October day training Boston, MA Charles Swenson, MD Behavior Technology Transfer Group 4556 University Way NE, Suite 221 *Training in the theory and application of Dialectical Behavior Therapy in Individual Psychotherapy Uncovering Dangerous Secrets: Suicide, Violence & Difficult Personality Disorders March day training Chester, VT Shawn Christopher Shea, MD *Training in suicide/homicide risk assessment and interviewing strategies for clients with severe Axis II disorders DBT for Substance Abusers October, day training Boston, MA The Wyndam Hotel Linda Dimeff, Ph.D. Behavior Technology Transfer Group 4556 University Way NE, Suite 221 Training in adaptations of Dialectical Behavior Therapy for the treatment of substance abusers Dialectical Behavior Therapy November, day workshop Waterford, ME Jan Watts, MS & Mary Buttitta, MS, LCMHC Behavior Technology Transfer Group 4556 University Way NE, Suite 221

7 Introductory Training in Dialectical Behavior Therapy. Catatogas Counselor/Teacher Training 12/28/94 1/21/95 Lakeland, FL Eckerd Youth Alternatives, Inc. PO Box 7450 Clearwater, FL *Training in the theory and application of Reality Therapy and Therapeutic Crisis Intervention for adjudicated adolescents Certification to practice in the Eckerd Wilderness Education Program *Note: Although I was awarded certificates of participation that qualified for Continuing education credits, these credits were not applicable because I am not licensed and was still a graduate student.

Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Updated February 2015 Disclosure for:

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