Fairview Health Services SPONSORED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Professional Practitioner Scope of Practice

Size: px
Start display at page:

Download "Fairview Health Services SPONSORED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Professional Practitioner Scope of Practice"

Transcription

1 Fairview Health Services SPONSORED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Professional Practitioner Scope of Practice PAGE 1 OF 3 Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity Inpatient/hospital(s) Fairview Maple Grove Medical Center (Ambulatory Care Center) 1, 2 Fairview Maple Grove Ambulatory Surgery Center 1 Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Ambulatory Clinics 1 I need to the following Fairview Entity Box on Privilege Form Individual Fairview hospital(s) University of Minnesota Medical Center, Fairview (UMMC) Fairview Maple Grove Ambulatory Surgery Center (MGASC) Individual Fairview hospital where clinic is affiliated Fairview Group Practice Ambulatory Clinics (FV Clinics) 1 Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel. 2 Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites. 3 Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with procedures available at the clinic. Education: Licensure: THRESHOLD CRITERIA Applicant must hold a minimum of a Master s Degree from an accredited university in Psychology, Social Work, Counseling, Marriage and Family Therapy, Psychiatric Nursing, or equivalent Behavioral discipline. Applicant must be licensed (certified or registered) in the State of Minnesota in the appropriate specialty. Documentation: Applicant must provide satisfactory documentation of competence for any specialized services they wish to include within their scope of practice. Sponsorship: Applicant must submit a Fairview Allied Health Professional Sponsorship form completed by an LIP at University of Minnesota Medical Center or qualified member of the Medical Staff in good standing at the Fairview entity to which the applicant is applying. The sponsorship form is attached to this privilege form. Z:\common\forms\cvo\Privilege Forms\Mental Health Service Provider-Master s Level.doc Approved: 6/02; 6/09 (new format);9/12; 4/13;6/14

2 PAGE 2 OF 3 Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FSH - Fairview Southdale Hospital FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical Center Fairview Ambulatory Entity Code FV Clinics = Fairview Free-standing Ambulatory Clinics MGASC = Fairview Maple Grove Ambulatory Surgery Center Definitions/Abbreviations Core Privileges - Privileges routinely taught in residency/fellowship programs Special Request Privileges - Privileges not routinely taught in residency/fellowship programs; new technology or procedure; high risk; or requires ongoing practice to maintain competency N/A - Indicates privilege not available at the specific Fairview entity AF - Indicates an additional form is required to request the privilege SUPERVISED MASTER S-LEVEL MENTAL HEALTH SERVICE PROVIDER Threshold Criteria Must meet Threshold Criteria listed on page 1 Scope of Practice i The mental health practitioner may treat only patients of sponsoring LIP or qualified Medical staff member as identified above. i Completion of appropriate documentation in accordance with facility standards. PATIENT POPULATIONS Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory UMMC FSH FRH FNH FLH FV Clinics Please identify the patient populations for whom you wish to provide services and that are within your scope of practice based on your training and supervised experience: Children Adolescents Adults Older Adults Medical Patients Mental Health Inpatients Mental Health Outpatients ASSESSMENT SERVICES - ADMINISTRATION ONLY Administration of psychological tests and assessments, assisting in psychological diagnosis in conjunction with a LIP sponsor and, as appropriate, in coordination with multidisciplinary treatment team. ASSESSMENT SERVICES - ADMINISTRATION AND INTERPRETATION Administration and interpretation of psychological instruments, assisting in psychological diagnosis in conjunction with a LIP sponsor and, as appropriate, in coordination with multidisciplinary treatment team. Please check below which, if any, of the following assessment services you wish to provide that are within your scope of practice based on training and/or supervised experience. Each of the assessment services requires specific documentation of training and/or supervised experience in the administration and interpretation of assessment techniques. Forensic assessment Mental Status Examination Objective Personality Assessment Psychoeducational Assessment Intellectual Assessment Neuropsychological Assessment Projective Personality Assessment Vocational Assessment Documentation must be within the last two years and in one or more of the following forms: 1) Letter from a training program attesting to competence for each modality specified. 2) Letter or certificate from a training course for each modality specified. 3) Peer Competency Assessment for Special Request Privileges form completed by a qualified peer attesting to your competency to perform the specific procedure(s). Form is enclosed in application packet; additional copies may be made if necessary. Continued on next page

3 PAGE 3 OF 3 INTERVENTION SERVICES - CORE Provision of psychotherapy using appropriate modalities under the sponsor s supervision and, as appropriate, in coordination with treatment team. INTERVENTION SERVICES - SPECIALIZED Please check below which, if any, of the following specialized services you wish to provide that are within your scope of practice based on your training and/or supervised experience. Each of the specialized services requires specific documentation of training and/or supervised experience. Behavior Modification Hypnosis Pain Management Biofeedback Group Therapy Sex Therapy Couples, Marital, or Family Therapy Documentation must be within the last two years and in one or more of the following forms: 1) Letter from a training program attesting to competence for each modality specified. 2) Letter or certificate from a training course for each modality specified. 3) Peer Competency Assessment for Special Request Privileges form completed by a qualified peer attesting to your competency to perform the specific procedure(s). Form is enclosed in application packet; additional copies may be made if necessary. TELEHEALTH BHP DEC SPONSORED SERVICES Threshold Criteria Education: Applicant must hold a minimum of a Master s Degree from an accredited university in Social Work (MSW), or a Doctorate in Psychology, Education or related field (PhD, EdD). Licensure: Applicant must be licensed (certified or registered) in the State of Minnesota in the appropriate specialty (LICSW or LP). Sponsorship: Applicant must submit a Fairview Allied Health Professional Sponsorship form completed by the BHP Chief Medical Officer. Other: Must be a qualified Behavioral HealthCare DEC Sponsored Provider Core Privileges SCOPE OF PRACTICE: Provides diagnosis and treatment of psychological function, disability, impairment, including addictions and emotional, mental and behavioral disorders, including plans based on a differential diagnosis, via the DEC web based electronic system. *Completed and signed Professional Staff Sponsorship Form Required* Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory UMMC FSH FRH FNH FLH FV Clinics N/A I attest that my professional liability insurance covers the responsibilities listed. Signature

4 PROFESSIONAL STAFF SPONSORSHIP FORM Professional Staff Practitioner s Name Sponsoring Physician s Name: (Sponsoring physician must be a member in good standing of the Medical Staff at the entity(ies) to which the applicant is applying) SPONSORING PHYSICIAN STATEMENT: I support the application of the above named individual for the services requested and agree to all of the terms, conditions and obligations associated with my supervising/sponsoring said individual as specified in the policies and rules of the Fairview entity(ies) to which applicant is applying. Sponsoring Physician Name PLEASE PRINT GROUP PRACTICE SUPERVISION In the event the above named individual for the services requested above will be supervised by several practitioners in a group practice, the group practice (name of group) shall support the application of the above named individual for the services requested and agree to all the terms, conditions and obligations associated with the supervision of said individual as specified in the policies and rules of the Fairview entity(ies) to which the applicant is applying relevant to the individual s practice at the hospital. The group practice promises that any practitioners providing the supervision shall be a member in good standing of the medical staff of the Fairview entity(ies) to which applicant is applying. Officer of Group c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06; 10/10

5 PROFESSIONAL STAFF PERFORMANCE REVIEW FORM Professional Staff Practitioner s Name: Sponsoring Physician s Name: Instructions for Sponsoring Physician: The above-named practitioner has applied for Professional Staff appointment or reappointment at a Fairview entity(ies). Please complete this form to provide an evaluation of the practitioner s current clinical competence. Thank you. 1. Complete each of the criteria below based on demonstrated performance compared to that reasonably expected of a Professional Staff at his/her level of training, experience, and background. A = Acceptable, U = Unacceptable, N.O. = Not observed. CRITERIA A U N.O. COMMENTS Basic job knowledge, competence and skill Service orientation Ethical conduct/hipaa compliance Professional judgment Cooperativeness, ability to work with others Sense of responsibility (work timely, meet professional standards, completion of responsibilities, responsiveness to supervision) 2. The practitioner is capable of performing duties within the scope of his/her services as listed on the scope of practice. (If no, please comment below) 3. Is the overall quality of the patient care provided by the practitioner appropriate and acceptable? (If no, please comment below) Yes Yes No No Comments: RECOMMENDATION: Recommend Recommend with the following reservation(s) Do not recommend (please provide explanation in comment section) Sponsoring Physician Name PLEASE PRINT Return completed form to: c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06 Fairview System Credentialing Office 2344 Energy Park Dr, Ste 127 St Paul, MN 55108

Fairview Health Services SURGICAL TECHNOLOGIST Professional Practitioner Scope of Practice CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

Fairview Health Services SURGICAL TECHNOLOGIST Professional Practitioner Scope of Practice CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES PAGE 1 OF 3 Fairview Health Services SURGICAL TECHNOLOGIST Professional Practitioner Scope of Practice Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the

More information

Fairview Health Services CERTIFIED NURSE MIDWIFE Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

Fairview Health Services CERTIFIED NURSE MIDWIFE Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES PAGE 1 OF 4 Fairview Health Services CERTIFIED NURSE MIDWIFE Delineation of Privileges Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview

More information

PSYCHOLOGIST CLINICAL PRIVILEGES

PSYCHOLOGIST CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 05/07/2014 Applicant: Check off the Requested box for

More information

DETROIT MEDICAL CENTER CLINICAL PRIVILEGES IN PSYCHOLOGY

DETROIT MEDICAL CENTER CLINICAL PRIVILEGES IN PSYCHOLOGY CLINICAL PRIVILEGES IN PSYCHOLOGY Page 1 of 4 PSYCHOLOGY: 1) Doctorate (Ph.D., Psy.D. or Ed.D.) in clinical psychology or a closely allied area of psychology. 2) Successful completion of an internship

More information

PSYCHIATRY CLINICAL PRIVILEGES

PSYCHIATRY CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 4/3/2013. Applicant: Check off the Requested box for

More information

Fairview Health Services CLINICAL NURSE SPECIALIST Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

Fairview Health Services CLINICAL NURSE SPECIALIST Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES Fairview Health Services CLINICAL NURSE SPECIALIST Delineation of PAGE 1 OF 9 Applicant s Name (please print): CROSSWALK F REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity

More information

PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER CLINICAL PRIVILEGES

PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment Department Specialty Area All new applicants must meet the following requirements as approved by the governing body effective: 6/3/15 Applicant: Check off

More information

Code of Virginia Board of Psychology

Code of Virginia Board of Psychology Code of Virginia Board of Psychology 54.1-3600. Definitions. As used in this chapter, unless the context requires a different meaning: "Applied psychologist" means an individual licensed to practice applied

More information

DEFINITIONS: The following definitions will apply to this Policy:

DEFINITIONS: The following definitions will apply to this Policy: CLASSIFICATION: MEDICAL STAFF POLICY NUMBER: MS004 EFFECTIVE DATE: 08/91 SUBJECT: Allied Health Professionals DATE REVIEWED/ REVISED: 03/97, 09/01, 06/03, 12/03, 09/04, 11/08, 2/09, 2/10, 3/12, 2/13, 3/13,

More information

GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS

GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 GUIDELINES FOR PSYCHOLOGICAL PRACTICE IN HEALTH CARE DELIVERY SYSTEMS INTRODUCTION Psychologists practice in an increasingly diverse range

More information

American Society of Addiction Medicine

American Society of Addiction Medicine American Society of Addiction Medicine Public Policy Statement on Treatment for Alcohol and Other Drug Addiction 1 I. General Definitions of Addiction Treatment Addiction Treatment is the use of any planned,

More information

Allied Health Care Provider: Appointment and Re-appointment

Allied Health Care Provider: Appointment and Re-appointment Allied Health Care Provider: Appointment and Re-appointment Document Owner: Lawson, Louise Version: 8 Effective Date: 10/23/2013 Revision Date: 4/26/2015 Approvers: Calkins, Paul; Del Boccio, Suzanne;

More information

Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners

Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

Behavioral Health and Human Services Licensing Board

Behavioral Health and Human Services Licensing Board Behavioral Health and Human Services Licensing Board SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS, MENTAL HEALTH COUNSELORS, AND ADDICTION COUNSELORS A compilation of the Indiana Code and Indiana Administrative

More information

PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY Bariatric Surgery

PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY Bariatric Surgery STANDARDS FOR PRIVILEGES In order to be eligible to request clinical privileges for both initial appointment and reappointment, a practitioner must the following minimum threshold criteria. In addition

More information

JEROLD M. GRODIN, Ph.D. 526 Maple Avenue Saratoga Springs, New York 12866 Tel.: (518) 587-4161 Fax: (518) 587-5134

JEROLD M. GRODIN, Ph.D. 526 Maple Avenue Saratoga Springs, New York 12866 Tel.: (518) 587-4161 Fax: (518) 587-5134 ACADEMIC HISTORY: JEROLD M. GRODIN, Ph.D. 526 Maple Avenue Saratoga Springs, New York 12866 Tel.: (518) 587-4161 Fax: (518) 587-5134 1985-1988 Postdoctoral Program in Psychotherapy 1983 Ph.D. Counseling

More information

Public Act No. 15-226

Public Act No. 15-226 Public Act No. 15-226 AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR MENTAL OR NERVOUS CONDITIONS. Be it enacted by the Senate and House of Representatives in General Assembly convened: Section 1. Section

More information

Post-Doctoral Fellowship in Clinical Psychology 2016-2017

Post-Doctoral Fellowship in Clinical Psychology 2016-2017 Post-Doctoral Fellowship in Clinical Psychology 2016-2017 Child and Family Psychological Services Inc./Integrated Behavioral Associates is a multi-disciplinary behavioral health care group dedicated to

More information

The role of behavioral health providers in a clinical quality management system. COL John C. Bradley, M.D. US Army

The role of behavioral health providers in a clinical quality management system. COL John C. Bradley, M.D. US Army The role of behavioral health providers in a clinical quality management system COL John C. Bradley, M.D. US Army How do we incorporate a full range of behavioral health providers in a clinical quality

More information

SENATE BILL NO. 2155

SENATE BILL NO. 2155 .00.0000 Sixty-second of North Dakota SENATE BILL NO. Introduced by Senator J. Lee A BILL for an Act to create and enact two new sections to chapter - of the North Dakota Century Code, relating to certification

More information

Policies of the University of North Texas Health Science Center. Chapter 14 UNT Health. 14.340 Credentialing and Privileging Licensed Practitioners

Policies of the University of North Texas Health Science Center. Chapter 14 UNT Health. 14.340 Credentialing and Privileging Licensed Practitioners Policies of the University of North Texas Health Science Center 14.340 Credentialing and Privileging Licensed Practitioners Chapter 14 UNT Health Policy Statement. UNT Health shall credential and grant

More information

Jin Nothmann, Psy.D. 66 Painter s Mill Road Suite 204 Owings Mills, MD 21117 (443) 394-0768, ext. 5

Jin Nothmann, Psy.D. 66 Painter s Mill Road Suite 204 Owings Mills, MD 21117 (443) 394-0768, ext. 5 1 Jin Nothmann, Psy.D. 66 Painter s Mill Road Suite 204 Owings Mills, MD 21117 (443) 394-0768, ext. 5 Licensure: State of Maryland Psychologist License #3762 Education 12/95-5/15/99 Psy.D. Clinical Psychology

More information

GRADUATE PROFESSIONAL COUNSELOR

GRADUATE PROFESSIONAL COUNSELOR CHAPTER 91 GRADUATE PROFESSIONAL COUNSELOR 9100 GENERAL PROVISIONS 9100.1 This chapter shall apply to applicants for and holders of a license to practice as a graduate professional counselor. 9100.2 Chapters

More information

Professional Counselor Examiners Committee Laws

Professional Counselor Examiners Committee Laws 45:8B-34. Short title 1. This act shall be known and may be cited as the "Professional Counselor Licensing Act." L.1993,c.340,s.1; per s.20 of 1993, c.340, act to expire if 45:8B-35. Determinations 2.

More information

Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012)

Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012) Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012) Executive Summary of Policy Contained in this Paper Summaries will lack rationale and background

More information

Counseling Psychology Program. CNP 4751 Counseling Psychology M.A. Internship. CNP 4762 School Counseling Internship 2

Counseling Psychology Program. CNP 4751 Counseling Psychology M.A. Internship. CNP 4762 School Counseling Internship 2 Counseling Psychology Program CNP 4751 Counseling Psychology M.A. Internship CNP 4762 School Counseling Internship 2 M.A. INTERNSHIP PACKET 2014-2015 1. Introduction to Master s Internship 2. Field Supervisor

More information

INFORMATION FOR APPLICANTS FOR LICENSURE AS A PSYCHOLOGIST

INFORMATION FOR APPLICANTS FOR LICENSURE AS A PSYCHOLOGIST INFORMATION FOR APPLICANTS FOR LICENSURE AS A PSYCHOLOGIST Enclosed are the application materials to practice as a Licensed Psychologist in Kentucky under the provisions of KRS 319. A copy of the law and

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

For each proctoring situation the group recommending proctoring must specify:

For each proctoring situation the group recommending proctoring must specify: Category: Subject: Purpose: Principles Medical Staff Proctoring Policy To objectively assess a practitioner s clinical competence related to a specific procedure or type of procedures. Training provided

More information

LAC+USC MEDICAL CENTER & HEALTHCARE NETWORK ATTENDING STAFF ASSOCIATION DELINEATION OF PRIVILEGES FOR THE DEPARTMENT OF DERMATOLOGY

LAC+USC MEDICAL CENTER & HEALTHCARE NETWORK ATTENDING STAFF ASSOCIATION DELINEATION OF PRIVILEGES FOR THE DEPARTMENT OF DERMATOLOGY LAC+USC MEDICAL CENTER & HEALTHCARE NETWORK ATTENDING STAFF ASSOCIATION FOR THE DEPARTMENT OF DERMATOLOGY NAME OF APPLICANT DATE Initial Appointment and/or Additional Privileges Reappointment Applicant:

More information

Department of Mental Health and Addiction Services 17a-453a-1 2

Department of Mental Health and Addiction Services 17a-453a-1 2 17a-453a-1 2 DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES General Assistance Behavioral Health Program The Regulations of Connecticut State Agencies are amended by adding sections 17a-453a-1 to 17a-453a-19,

More information

InteCare Addendum to CAQH Application

InteCare Addendum to CAQH Application InteCare Addendum to CAQH Application I. Required Provider Information Needed for CAQH Last Name First Name Organization Name Group NPI Number CAQH Number Social Security Number Provider Type (License

More information

CLINICAL PRIVILEGES- NURSE ANESTHETIST

CLINICAL PRIVILEGES- NURSE ANESTHETIST Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 8/5/2015. Applicant: Check off the Requested box for

More information

VITA. Bucknell University B.A. 1980 Economics Lewisburg, PA M.S.Ed. 1984 School Psychology

VITA. Bucknell University B.A. 1980 Economics Lewisburg, PA M.S.Ed. 1984 School Psychology VITA Richard G. Salamone, Ph.D. 739 Bluff City Hwy, Suite 2 37620 Telephone/Fax: 423-968-3099/7385 E-mail: richardsalamone@aol.com January 2013 EDUCATION Bucknell University B.A. 1980 Economics Lewisburg,

More information

OUTPATIENT SERVICES. Components of Service

OUTPATIENT SERVICES. Components of Service OUTPATIENT SERVICES Providers contracted for this level of care or service are expected to comply with all requirements of these service-specific performance specifications. Additionally, providers contracted

More information

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at

More information

CURRENT MFT EDUCATIONAL REQUIREMENTS 4980.37. DEGREE PROGRAM; COURSE OF STUDY AND PROFESSIONAL TRAINING

CURRENT MFT EDUCATIONAL REQUIREMENTS 4980.37. DEGREE PROGRAM; COURSE OF STUDY AND PROFESSIONAL TRAINING CURRENT MFT EDUCATIONAL REQUIREMENTS 4980.37. DEGREE PROGRAM; COURSE OF STUDY AND PROFESSIONAL TRAINING (a) In order to provide an integrated course of study and appropriate professional training, while

More information

# Category Standard Provisional Standard Notes/Comments

# Category Standard Provisional Standard Notes/Comments Page1 1 Service Definition/ Required Components Therapeutic Rehabilitation Program is rehabilitative service for adults with SMI and children with SED designed to maximize reduction of mental disability

More information

Basic Standards for Residency Training in Child and Adolescent Psychiatry

Basic Standards for Residency Training in Child and Adolescent Psychiatry Basic Standards for Residency Training in Child and Adolescent Psychiatry American Osteopathic Association and American College of Osteopathic Neurologists and Psychiatrists Adopted 1980 Revised, 1984

More information

So, you want to be a mental health professional?

So, you want to be a mental health professional? So, you want to be a mental health professional? Jim Graham The practice of therapy/counseling/psychotherapy falls within the scope of practice of several licensures 1 Licensure types and requirements

More information

Mental Health. HP Provider Relations

Mental Health. HP Provider Relations Mental Health Guidelines and Billing Practices HP Provider Relations July 2011 Agenda Session Objectives Outpatient Mental Health Medicaid Rehabilitation Option (MRO) Risk-Based Managed Care (RBMC) Eligibility

More information

Anthem Credentialing Programs Standards

Anthem Credentialing Programs Standards Anthem Credentialing Programs Standards A. Eligibility Criteria Health Care Practitioners Initial applicants must meet the following criteria in order to be considered for participation: 1. Possess a current,

More information

262 CMR 2.00: Requirements For Licensure As a Mental Health Counselor

262 CMR 2.00: Requirements For Licensure As a Mental Health Counselor 262 CMR 2.00: Requirements For Licensure As a Mental Health Counselor 2.01: Preface 2.02: Definitions 2.03: Licensure Application Requirements 2.04: Education and Degree Requirements Pre-July 1, 2017 2.05:

More information

CONNECTICUT GENERAL STATUTES CHAPTER 383c PROFESSIONAL COUNSELORS

CONNECTICUT GENERAL STATUTES CHAPTER 383c PROFESSIONAL COUNSELORS CONNECTICUT GENERAL STATUTES CHAPTER 383c PROFESSIONAL COUNSELORS Sec. 20-195aa. Definitions: As used in sections 20-195aa to 20-195ee, inclusive: "Professional counseling" means the application, by persons

More information

CLINICAL PRIVILEGE WHITE PAPER Psychology

CLINICAL PRIVILEGE WHITE PAPER Psychology Psychology CLINICAL PRIVILEGE WHITE PAPER Psychology Background Psychology is a broad field that includes the scientific study of mental processes and behavior. It is similar to the medical field of psychiatry.

More information

Sixty-second Legislative Assembly of North Dakota In Regular Session Commencing Tuesday, January 4, 2011

Sixty-second Legislative Assembly of North Dakota In Regular Session Commencing Tuesday, January 4, 2011 Sixty-second Legislative Assembly of North Dakota In Regular Session Commencing Tuesday, January 4, 2011 SENATE BILL NO. 2155 (Senator J. Lee) AN ACT to create and enact two new sections to chapter 43-32

More information

Curriculum Vitae Gay Rosenthal, M.A., L.P. Nationally Certified School Psychologist Certification Number 10529

Curriculum Vitae Gay Rosenthal, M.A., L.P. Nationally Certified School Psychologist Certification Number 10529 Curriculum Vitae Gay Rosenthal, M.A., L.P. Personal Data Office Address Licensure Certification Qualified Neutral Traverse Counseling and Consulting 11812 Wayzata Boulevard Suite 100 Minnetonka, Minnesota

More information

ADMINISTRATIVE RULES FOR CLINICAL SOCIAL WORKERS TABLE OF CONTENTS

ADMINISTRATIVE RULES FOR CLINICAL SOCIAL WORKERS TABLE OF CONTENTS ADMINISTRATIVE RULES FOR CLINICAL SOCIAL WORKERS TABLE OF CONTENTS PART 1. GENERAL INFORMATION ON LICENSURE OF CLINICAL SOCIAL WORKERS 1.1 THE PURPOSE OF LICENSURE...1 1.2 BUSINESS LOCATION...1 1.3 ADVISORS

More information

Psychology Externship Program

Psychology Externship Program Psychology Externship Program The Washington VA Medical Center (VAMC) is a state-of-the-art facility located in Washington, D.C., N.W., and is accredited by the Joint Commission on the Accreditation of

More information

The Collaborative Models of Mental Health Care for Older Iowans. Model Administration. Collaborative Models of Mental Health Care for Older Iowans 97

The Collaborative Models of Mental Health Care for Older Iowans. Model Administration. Collaborative Models of Mental Health Care for Older Iowans 97 6 The Collaborative Models of Mental Health Care for Older Iowans Model Administration Collaborative Models of Mental Health Care for Older Iowans 97 Collaborative Models of Mental Health Care for Older

More information

Phoenix, Arizona. Department of Psychiatry. Rules and Regulations

Phoenix, Arizona. Department of Psychiatry. Rules and Regulations Phoenix, Arizona Department of Psychiatry Rules and Regulations ARTICLE I ARTICLE II ARTICLE III Organization Functions and Duties Miscellaneous Provisions ARTICLE IV Organization Section 1 In accordance

More information

Forensic Pathology Clinical Privileges

Forensic Pathology Clinical Privileges Name: Effective from _/ _/ to / / Initial privileges (initial appointment) Renewal of privileges (reappointment) All new applicants must meet the following requirements as approved by the governing body,

More information

Fairview Health Services NURSE PRACTITIONER Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

Fairview Health Services NURSE PRACTITIONER Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES Fairview Health Services NURSE PRACTITIONER Delineation of PAGE 1 OF 12 Applicant s Name (please print): CROSSWALK F REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity I need

More information

Nebraska Mental Health Practitioner Licensure Examination Information

Nebraska Mental Health Practitioner Licensure Examination Information Nebraska Mental Health Practitioner Licensure Examination Information Dear Examination Applicant: The following provides information relating to the examination process. If you have further questions,

More information

4.401 Substance Use Partial Hospitalization Program (Adults and Adolescents)

4.401 Substance Use Partial Hospitalization Program (Adults and Adolescents) 4.40 STRUCTURED DAY TREATMENT SERVICES 4.401 Substance Use Partial Hospitalization Program (Adults and Adolescents) Description of Services: Substance use partial hospitalization is a nonresidential treatment

More information

STATE OF OKLAHOMA. 2nd Session of the 53rd Legislature (2012) AS INTRODUCED

STATE OF OKLAHOMA. 2nd Session of the 53rd Legislature (2012) AS INTRODUCED STATE OF OKLAHOMA nd Session of the rd Legislature () SENATE BILL AS INTRODUCED By: Brecheen An Act relating to sexual exploitation by a mental health services provider; creating the Protection Against

More information

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies

Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product

More information

STRUCTURED OUTPATIENT ADDICTION PROGRAM (SOAP)

STRUCTURED OUTPATIENT ADDICTION PROGRAM (SOAP) STRUCTURED OUTPATIENT ADDICTION PROGRAM (SOAP) Providers contracted for this level of care or service are expected to comply with all requirements of these service-specific performance specifications.

More information

ARTICLE ## LICENSED MENTAL HEALTH COUNSELOR

ARTICLE ## LICENSED MENTAL HEALTH COUNSELOR ARTICLE ## LICENSED MENTAL HEALTH COUNSELOR Section #####1. Definitions. Section #####2. Qualifications for Licensure. Section #####3. Exceptions to Licensure. Section #####4. Scope of Practice. Section

More information

MENTAL HEALTH PRACTICE ACT

MENTAL HEALTH PRACTICE ACT 2013 STATE OF NEBRASKA STATUTES RELATING TO MENTAL HEALTH PRACTICE ACT MARRIAGE AND FAMILY THERAPY PROFESSIONAL COUNSELING SOCIAL WORK Department of Health and Human Services Division of Public Health

More information

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process.

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process. Credentialing and Privileging of Licensed Independent Practitioners The following standards apply to individuals permitted by law and the organization to provide patient care services without direction

More information

Matthew Capezzuto, Ph.D., MSSA, LISW-S 31170 Muirfield Way, Westlake, Ohio 44145 (440) 666-4712

Matthew Capezzuto, Ph.D., MSSA, LISW-S 31170 Muirfield Way, Westlake, Ohio 44145 (440) 666-4712 Matthew Capezzuto, Ph.D., MSSA, LISW-S 31170 Muirfield Way, Westlake, Ohio 44145 (440) 666-4712 TEACHING Argosy University Assistant Professor, College of Psychology and Behavioral Sciences 2008-present

More information

Post-Doctoral Fellowship in Clinical Psychology

Post-Doctoral Fellowship in Clinical Psychology SULLIVAN CENTER FOR CHILDREN 2015-2016 Post-Doctoral Fellowship in Clinical Psychology 3443 W. Shaw Fresno, California 93711 Phone: 559-271-1186 Phone: 559-271-1186 Fax: 559-271-8041 E-mail: markbarnes@sc4c.com

More information

CLINICAL SOCIAL WORKER LICENSURE APPLICATION

CLINICAL SOCIAL WORKER LICENSURE APPLICATION P.O. Box 110806, Juneau, Alaska 99811-0806 Telephone: (907) 465-2551 E-mail: license@alaska.gov Website: www.commerce.alaska.gov/occ CLINICAL SOCIAL WORKER LICENSURE APPLICATION READ THESE INSTRUCTIONS

More information

CLINICAL REHABILITATION COUNSELING

CLINICAL REHABILITATION COUNSELING CLINICAL REHABILITATION COUNSELING Students who are preparing to work as rehabilitation counselors will demonstrate the professional knowledge, skills, and practices necessary to address a wide variety

More information

MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION

MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION NOTE: DO NOT USE THIS APPLICATION FOR OWNERSHIP CHANGES.

More information

Education Standards For Education Programs Providing Post Master s Art Therapy Master s Degrees Effective Date: January 1, 2008

Education Standards For Education Programs Providing Post Master s Art Therapy Master s Degrees Effective Date: January 1, 2008 Education Standards For Education Programs Providing Post Master s Art Therapy Master s Degrees Effective Date: January 1, 2008 MISSION STATEMENT The, Inc. (AATA) is an organization of professionals dedicated

More information

Psychology and Gastroenterology: Keys to Effective Integration. Anthony Alioto, Ph.D. Pediatric Psychologist Clinical Lead, GI Psychological Services

Psychology and Gastroenterology: Keys to Effective Integration. Anthony Alioto, Ph.D. Pediatric Psychologist Clinical Lead, GI Psychological Services Psychology and Gastroenterology: Keys to Effective Integration Anthony Alioto, Ph.D. Pediatric Psychologist Clinical Lead, GI Psychological Services Nationwide Children s Hospital Columbus, Ohio Disclosures

More information

Social Work Education

Social Work Education Social Work Education Presented to: Minnesota Medical Education and Research Cost (MERC) Committee by Lisa Richardson, MSS, LICSW Director of MSW Field Education St. Catherine University and the University

More information

ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES CLASS SPECIFICATION PSYCHOLOGIST CLASS SERIES CLASS TITLE POSITION CODE EFFECTIVE DATE

ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES CLASS SPECIFICATION PSYCHOLOGIST CLASS SERIES CLASS TITLE POSITION CODE EFFECTIVE DATE ILLINOIS DEPARTMENT OF CENTRAL MANAGEMENT SERVICES CLASS SPECIFICATION PSYCHOLOGIST CLASS SERIES CLASS TITLE POSITION CODE EFFECTIVE DATE PSYCHOLOGIST I 35611 07-01-04 PSYCHOLOGIST II 35612 07-01-04 PSYCHOLOGIST

More information

Laura LoBuglio-Vigil, Psy.D. Licensed Clinical Psychologist (PY5852) 5803 N.W. 151 Street, Ste. 203 Miami Lakes, FL. 33014 (305) 557-8855

Laura LoBuglio-Vigil, Psy.D. Licensed Clinical Psychologist (PY5852) 5803 N.W. 151 Street, Ste. 203 Miami Lakes, FL. 33014 (305) 557-8855 Laura LoBuglio-Vigil, Psy.D. Licensed Clinical Psychologist (PY5852) 5803 N.W. 151 Street, Ste. 203 Miami Lakes, FL. 33014 (305) 557-8855 Education: August, 1993 - September, 1997 Doctor of Psychology

More information

CLINICAL PRIVILEGE WHITE PAPER

CLINICAL PRIVILEGE WHITE PAPER Practice Area 403 CLINICAL PRIVILEGE WHITE PAPER Background Occupational therapist Occupational therapists (OTs) use specialized knowledge to help individuals improve their ability to perform tasks in

More information

Allied Health Professional Rules and Regulations

Allied Health Professional Rules and Regulations Allied Health Professional Rules and Regulations I. Purpose To maintain an organized Allied Health Professional Staff committed to promoting effective delivery of patient services, and continuous review

More information

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals

Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals IOWA PLAN F BEHAVIAL HEALTH RE: Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals The purpose of this document is to clarify who can provide which outpatient services

More information

Treatment Services for Individuals with Co-Occurring Mental Health and Intellectual Disability/Developmental Disabilities

Treatment Services for Individuals with Co-Occurring Mental Health and Intellectual Disability/Developmental Disabilities Two types of individuals 1. People with primary diagnosis of intellectual disability/developmental disability Mental health diagnosis is secondary Primary services through ID/DD system Residential/Housing

More information

POSITION DESCRIPTION. Clinical Psychologist AT & R Unit, Middlemore Hospital

POSITION DESCRIPTION. Clinical Psychologist AT & R Unit, Middlemore Hospital POSITION DESCRIPTION Clinical Psychologist AT & R Unit, Middlemore Hospital Date Produced/Reviewed: 22 nd February 2010 Position Holder's Name : Position Holder's Signature :... Manager / Supervisor's

More information

Behavioral Mental Health Care Career Guide P199, Dr. Patton Part 3. Decisions about License & Degree Program

Behavioral Mental Health Care Career Guide P199, Dr. Patton Part 3. Decisions about License & Degree Program Behavioral Mental Health Care Career Guide P199, Dr. Patton Part 3. Decisions about License & Degree Program All licensed mental health care professionals no matter whether they are generalists or specialists

More information

BEHAVIORAL MEDICINE CODING AND BILLING GUIDE DEVELOPED: FEBRUARY 2005

BEHAVIORAL MEDICINE CODING AND BILLING GUIDE DEVELOPED: FEBRUARY 2005 BEHAVIORAL MEDICINE CODING AND BILLING GUIDE DEVELOPED: FEBRUARY 2005 This is a matrix of basic coding and billing information, arranged by payer, for coding and billing guidance. It should be used in

More information

Procedure/ Revenue Code. Billing NPI Required. Rendering NPI Required. Service/Revenue Code Description. Yes No No

Procedure/ Revenue Code. Billing NPI Required. Rendering NPI Required. Service/Revenue Code Description. Yes No No Procedure/ Revenue Code Service/Revenue Code Description Billing NPI Rendering NPI Attending/ Admitting NPI 0100 Inpatient Services Yes No Yes 0114 Room & Board - private psychiatric Yes No Yes 0124 Room

More information

Neal R. Morris, Ed.D., M.S. Child and Family Psychology Health Psychology

Neal R. Morris, Ed.D., M.S. Child and Family Psychology Health Psychology Neal R. Morris, Ed.D., M.S. Child and Family Psychology Health Psychology Office: Phone: 301-907-3471 4641 Montgomery Avenue, Suite 210 Fax: 301-907-0822 Bethesda, Maryland 20814 www.morristherapyoffice.com

More information

WRAPAROUND MILWAUKEE Policy & Procedure

WRAPAROUND MILWAUKEE Policy & Procedure WRAPAROUND MILWAUKEE Policy & Procedure Wraparound Wraparound-REACH FISS Project O-Yeah I. POLICY Date Issued: 11/15/07 Effective Date: 1/1/15 Reviewed: 10/20/14 By: WA Last Revision: 10/20/14 Subject:

More information

other caregivers. A beneficiary may receive one diagnostic assessment per year without any additional authorization.

other caregivers. A beneficiary may receive one diagnostic assessment per year without any additional authorization. 4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Attachment 3.1-A.1 Page 7c.2 (a) Psychotherapy Services: For the complete description of the service providers,

More information

Ambulatory Care Program: The Who, What, When, and Where s of Credentialing and Privileging. The Who, What, When, and Where s

Ambulatory Care Program: The Who, What, When, and Where s of Credentialing and Privileging. The Who, What, When, and Where s Ambulatory Care Program: The Who, What, When, and Where s of Credentialing and Privileging The Who, What, When, and Where s The Who, What, When, and Where s Note that this was originally documented as

More information

Psychology Internship Program

Psychology Internship Program Psychology Internship Program Welcome Thank you for your interest in the APA accredited Psychology internship program at Cherokee Health Systems (CHS). The primary goal of the internship is to provide

More information

Facility/Organizational Providers Approval Signatures: Available Upon Request

Facility/Organizational Providers Approval Signatures: Available Upon Request 12/04/2006, 7/2/2007, Page 1 of 20 I. Purpose: A. To ensure facility/organizational provider applicants meet ValueOptions of California (VOC) credentialing criteria. B. This policy replaces ValueOptions,

More information

(a) To qualify as a certified supervised counselor alcohol and drug, an applicant shall: (1) BE OF GOOD MORAL CHARACTER;

(a) To qualify as a certified supervised counselor alcohol and drug, an applicant shall: (1) BE OF GOOD MORAL CHARACTER; 2015 -Legislative Proposal 1- BOPCT Statute amendment: 1. Revise the BOPCT Statute to remove barriers Introduce legislation in collaboration with the Board of Professional Counselors and Therapists (BoPCT)

More information

Glenn Maynard, LPC 319 SW Washington, Suite 1015 Portland, OR 97204 (503) 916-8186 Fax: (503) 227-2561 E-mail: maynarg@comcast.net

Glenn Maynard, LPC 319 SW Washington, Suite 1015 Portland, OR 97204 (503) 916-8186 Fax: (503) 227-2561 E-mail: maynarg@comcast.net Glenn Maynard, LPC 319 SW Washington, Suite 1015 97204 (503) 916-8186 Fax: (503) 227-2561 E-mail: maynarg@comcast.net EDUCATION: M.Ed. Counseling, Lewis & Clark College 1977 BS Sociology, Portland State

More information

Indiana Behavioral Health and Human Services Licensing Board

Indiana Behavioral Health and Human Services Licensing Board Indiana Behavioral Health and Human Services Licensing Board A compilation of the Indiana Code and Indiana Administrative Code 2012 Edition Indiana Professional Licensing Agency Indiana Behavioral Health

More information

Telemedicine services. Crisis intervcntion response services, except

Telemedicine services. Crisis intervcntion response services, except Approved: MAY 2 4 2010 ATTACHMENT 3.1 -A Page 54j 4. Consultation with relatives, guardians, friends, employers, treatment providers, and other significant people, in order to change situations and allow

More information

PSYCHOTHERAPY: HOW TO GET STARTED

PSYCHOTHERAPY: HOW TO GET STARTED PSYCHOTHERAPY: HOW TO GET STARTED I didn t want to talk about my problems with someone I didn t know. Then I learned how common it is to initially feel hesitant and to even try several therapists before

More information

MOONLIGHTING INSTRUCTIONS:

MOONLIGHTING INSTRUCTIONS: MOONLIGHTING INSTRUCTIONS: Please Complete and Send the Forms on the Following 6 Pages to the Medical Staff Office at Box URMFG 278911. 1) URMC Moonlighting (extra work shift) Request Form, p. 1 of 6 2)

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Mental Health Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Mental Health Services DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Mental Health Services ICN 903195 September 2013 This booklet was current at the time it was published or uploaded onto

More information

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT (APN) In accordance with the Nursing and Advanced Practice Nursing Act (225 ILCS 65) (the Act ), the

More information

Division of Behavioral Health. Requirements for Program Staff

Division of Behavioral Health. Requirements for Program Staff Division of Behavioral Health Requirements for Program Staff Integrated BH Regulations Training 1 Program Staff Program Staff are professionals who render behavioral health services directly to a recipient.

More information

AMERICAN PSYCHOLOGICAL ASSOCIATION

AMERICAN PSYCHOLOGICAL ASSOCIATION A. Definitions AMERICAN PSYCHOLOGICAL ASSOCIATION MODEL LEGISLATION FOR PRESCRIPTIVE AUTHORITY Approved by APA Council of Representatives, 2009 (1) Board means the {state psychology licensing board}. (2)

More information

GUIDELINES FOR SUBMITTING AN INTERNSHIP APPLICATION TO THE PSYCHOLOGY DIVISION OF THE SIR MORTIMER B. DAVIS-JEWISH GENERAL HOSPITAL

GUIDELINES FOR SUBMITTING AN INTERNSHIP APPLICATION TO THE PSYCHOLOGY DIVISION OF THE SIR MORTIMER B. DAVIS-JEWISH GENERAL HOSPITAL GUIDELINES FOR SUBMITTING AN INTERNSHIP APPLICATION TO THE PSYCHOLOGY DIVISION OF THE SIR MORTIMER B. DAVIS-JEWISH GENERAL HOSPITAL Please note that these guidelines apply to students applying for all

More information

Credentialing and Privileging. Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center

Credentialing and Privileging. Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center Credentialing and Privileging Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center 1 The goal of this Continuing Education Program is to provide health care professionals with information

More information

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

Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Updated February 2015 Disclosure for: Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Updated February 2015 Disclosure for: CHRISTINE PAYNE Qualifications and Experience (See attached pages) My

More information

Keep Your Mind and Body Healthy: Understanding Mental Health Providers, Care and Coverage

Keep Your Mind and Body Healthy: Understanding Mental Health Providers, Care and Coverage Keep Your Mind and Body Healthy: Understanding Mental Health Providers, Care and Coverage Our mental health is a vital part of our overall well-being. It affects how we think, how we feel, and how we act.

More information

City: State: Zip Code:

City: State: Zip Code: ATTACHMENT D - Revised 3/27/14 STATE OF NEBRASKA Division of Public Health - Licensure Unit P.O. Box 94986 301 Centennial Mall South Lincoln, Nebraska 68509-4986 Telephone #: 402-471-4970 carrie.nielsen@nebraska.gov

More information