Licensed Clinical Mental Health Counselor Renewal Application

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Licensed Clinical Mental Health Counselor Renewal Application Board of Allied Mental Health Renewal Clerk (802) Current Expiration 01/31/2015 You Must Complete The Information Below: Renewal Period Covering 02/01/2015 through 01/31/2017 Renewal Application Fee $ [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received in the Office by the expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $ Reminder: You may not practice your licensed profession without an active license. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country Street/Apt # If your 911 address has changed, indicate your new address in the box to the right. Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.

3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3

4 Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal and conducts a random audit of CE for each profession. You must retain all documentation for seven years after completion of the program/course. Please complete the Continuing Education Record on the next page. If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Board of Allied Mental Health Administrative Rules 3.30 Maintaining a Clinical Mental Health Counselor License, Continuing Education Every licensed clinical mental health counselor must complete 40 continuing education credits in a 24-month renewal period in order to renew the license Continuing Education, Ethics Requirement, Supervision (a) A minimum of four of the 40 hours must be specifically designated as continuing education in professional ethics in the clinical fields of marriage and family therapy, clinical mental health counseling, psychiatry, psychology, or social work. The remaining 36 hours must be in the theory and practice of clinical mental health counseling. (b) Those who serve as supervisors are encouraged to take some continuing education training related to supervision Individualized Learning Activities (b) more than 20 of the 40 hours may be accrued in the category of Individualized Learning Activities. Continuing Education Requirement (Check the box that applies to your license.) My Licensed Clinical Mental Health Counselor license was first issued in Vermont on or after 02/01/2013; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Licensed Clinical Mental Health Counselor license was first issued in Vermont prior to 02/01/2013; and I have completed 40 hours of continuing education, including (4) four hours in professional ethics. I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4

5 Itemize the education courses taken over the past two years (submit additional sheets if more space is needed) TITLE & CONTENT OF PROGRAM SPONSORING ORGANIZATION # OF CREDITS/HOURS AWARDED DATES TOTAL # OF CREDITS/HOURS: Name (print): License Number: 5

6 Section E: Expired Renewal If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section F: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant **(REQUIRED)** Signature Date (MM/DD/YYYY) Print Name: License # ---- Name (print): License Number: 6

7 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2015 Renewal License #: Name: Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 7

8 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 1 Vermont License Number First Name - (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) Middle Name Last Name 1. Gender: Male Female 2. Are you Hispanic or Latino/a? Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Prefer not to answer Birthdate (mm-dd-yyyy) Race? (check all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or Pacific Islander White Other Prefer not to answer 4. What is your highest counseling degree? Master s degree in counseling or related field Doctoral degree in counseling or related field Other 5. In what year did you complete your initial counseling degree? 6. Enter the two-letter code for the state where you completed your initial counseling degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Was this a CACREP accredited program when you graduated? Don't know 8. Please check all counseling certifications you currently hold: National Certified Counselor (NCC) Approved Clinical Supervisor (ACS) Other 9. For how many years have you provided direct client care as a licensed Clinical Mental Health Counselor (in any state)? Please continue on next page. Thank you

9 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 2 Vermont License Number (Please re-enter your license number for scanning purposes) 9. Which of the following other licenses, certifications or registrations do you maintain? (Select all that apply) Art therapist Marriage & family therapist Psychoanalyst Psychologist 10. In what state(s) do you hold an active Clinical Mental Health Counselor license? State (postal abbreviation(s)) Social worker Substance abuse/addiction counselor Other 11. Please describe your current employment status: (check all that apply) Actively working in a position that requires a mental health counseling license Actively working in a position that does not require a mental health counseling license Actively working in a field other than mental health counseling t currently working Retired 12. Do you provide direct client care in Vermont as a Clinical Mental Health Counselor? 13. If no, do you plan to start (or resume) direct client care in Vermont as a Clinical Mental Health Counselor within the next 12 months? * IF you are not providing direct patient care IN VERMONT as a Clinical Mental Health Counselor, PLEASE STOP HERE AND RETURN SURVEY 14. For how many years have you provided direct client care in Vermont as a Clinical Mental Health Counselor? 15. What are your plans for the next 12 months regarding direct client care in Vermont? Increase hours in patient care Decrease hours in patient care Seek a non-clinical job Retire Continue as you are Unknown Please continue on next page. Thank you

10 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 3 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct client care IN VERMONT. If you provide care at 2 locations in the same town, please enter a separate site for each. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Practice name Street address (not a mailing address): ZIP code This site is a (please choose ONE): Community Health Center Mental Health Clinic Methadone Clinic Outpatient Medical Care Substance Abuse Treatment Facility Child welfare Criminal Justice Hospital: General Hospital: Psychiatric Private practice: individual Private practice: group Rehabilitation Residential setting School based mental health In-home setting Other: During how many weeks in a year do you work at this site as a Clinical Mental Health Counselor? (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct client care at this site? (select ONE) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

11 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 4 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct client care at this site? (if any) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your secondary specialty area mentioned above: Hours per week Please indicate the average number of hours you spend per working week at this site on additional major activities: Administration / Management If you have a second practice site, continue on the next page. If you only have one practice * site, stop here, but please return all 6 pages. Supervision Teaching / Education Research Other activities Please return all sheets (6 pages) even if some are blank. Thank you

12 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 5 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct client care IN VERMONT. If you provide care at 2 locations in the same town, please enter a separate site for each. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Practice name Street address (not a mailing address): ZIP code This site is a (please choose ONE): Community Health Center Mental Health Clinic Methadone Clinic Outpatient Medical Care Substance Abuse Treatment Facility Child welfare Criminal Justice Hospital: General Hospital: Psychiatric Private practice: individual Private practice: group Rehabilitation Residential setting School based mental health In-home setting Other: During how many weeks in a year do you work at this site as a Clinical Mental Health Counselor? (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct client care at this site? (select ONE) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you

13 58194 VERMONT DEPARTMENT OF HEALTH CENSUS OF MENTAL HEALTH COUNSELORS 2014 This census is designed to assess the distribution of mental health counselors throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 6 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct client care at this site? (if any) Alcoholism and substance abuse treatment Assessment and diagnosis Brief and solution-focused therapy Crisis management Psychoeducational and prevention programs Psychotherapy Treatment planning and utilization review Distance counseling (VT / other state) Case management Cognitive behavioral therapy Other: Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Please indicate the average number of hours of direct client care (excluding on-call hours) spent per working week at this site in your secondary specialty area mentioned above: Hours per week Please indicate the average number of hours you spend per working week at this site on additional major activities: Administration / Management Supervision Teaching / Education Research Other activities If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you