This form must be signed and returned with your application. Certification requirements can be found on page eleven of this application.

Transcription

1 This form must be signed and returned with your application. Certification requirements can be found on page eleven of this application. Name of Applicant: Application completed in its entirety Copy of degree/transcripts Four reference forms Copy of state license, if applicable Payment I have read and understand the minimum requirements for certification. I understand that if I submit an application for review and I do not meet the requirements for certification before examination is scheduled, my application will be denied and fees paid will be refunded with the exception of the $25.00 application fee, which is non-refundable. I understand that if my application is accepted and certification is granted, that it is my responsibility to study all standards, guidelines, policies and procedures, code of ethics, and other materials pertaining to NAFC and my certification. By submitting my application, I agree to follow all standards, guidelines, policies and procedures, code of ethics, and other materials pertaining to NAFC and my certification. I also understand that I must pass the NAFC certification examination. Once an examination is scheduled, no fees will be refunded. If I do not pass the certification examination, no fees will be refunded, and additional fees will be required to retake the examination. Signature of Applicant Date

2 This application must be completed in its entirety. Incomplete applications received will not be processed. If you have any questions about the application, please contact us. All requirements must be met and all information must be provided. No waivers will be granted for any part of this application. Date (Check only one): A separate application with supporting documentation is required for each credential. CCJS- Certified Criminal Justice Specialist CM CDVC- Certified Domestic Violence Counselor CM CFC- Certified Forensic Counselor CM CFSW Certified Forensic Social Worker CFI Certified Forensic Interviewer CSOTS- Certified Sex Offender Treatment Specialist CM CJSOTS- Certified Juvenile Sex Offender Treatment Specialist Check here if you are seeking the Clinical level for the certification you are applying Check here if you are exempt from licensure. If checked, you must select reason below and provide proof of exemption with your application: No licensure for my profession, i.e., probation parole, corrections, etc. Exempted from licensure legislatively. Federal/Government Employee, no license required. First Name MI Last Name Street Address City State ZIP Home Phone (optional) Work Phone (required) EXT. Primary (required) Secondary (optional) REFERENCES: Provide complete names, addresses and contact phone number of four (4) colleagues. All references must be professionals working in your professional field and not related to you. At least one reference must be your immediate supervisor. If you are in Private Practice and do not have an immediate supervisor, then this reference must be someone who has known you professionally for at least three (3) years. Letters of recommendation forms are provided at the end of this application. At least one must be filled out by your immediate supervisor, or someone who has known you professionally for at least three (3) years. Reference 1 - Supervisor: First Name Last Name Title Work Phone Address City State ZIP

3 Reference 2: First Name Last Name Title Work Phone Relationship to applicant, i.e., co-worker, supervisor, colleague, etc. Place of Employment Reference 3: First Name Last Name Title Work Phone Relationship to applicant, i.e., co-worker, supervisor, colleague, etc. Place of Employment Reference 4: First Name Last Name Title Work Phone Relationship to applicant, i.e., co-worker, supervisor, colleague, etc. Place of Employment Please list and attach a copy of your highest degree earned from an accredited educational institution, your state license - active and good standing where licensure is applicable (please read about licensure exemptions in the requirements section after this application), any other certifications currently held active and in good standing. Degree Earned: M.D. J.D. Psy.D. Ph.D. Masters Bachelors No Degree Other: University/College Major Year Graduated State License(s): (if you do not fall under license exemption as described in the requirements section after this application, you cannot obtain NAFC certification. Please read the information provided in the Requirements section about applying for an In- Service designation if you are currently in the process of applying for state licensure. State Licensed License Held License Number Expiration Date

4 Other Certification(s) held: (please list other certifications currently held active and in good standing) Issuing Organization Certification Held Certification Number Expiration Date Please attach copies of certificates of completion for any training, etc., that you feel would be appropriate for the certification commission s review. Are you currently an NAFC certified member active in good standing? Yes No If Yes, Please complete the following: NAFC Certification Held Certification Number Expiration date Have you previously applied for NAFC certification and your application was denied? Yes No If Yes, Please complete the following: NAFC Certification Applied For Reason for Denial Year Applied Have you ever had any state license in any profession in any field suspended or revoked? Yes No If Yes, Please complete the following: State Title of License Suspended/Revoked License Number Reason Outcome Have you ever had any certification by any organization suspended or revoked? Yes No If Yes, Please complete the following: Name of Organization Certification Suspended or Revoked Certification Number Reason Outcome

5 Please include the last three (3) years of full time paid or voluntary supervised employment relevant to this application, starting with your current position. In the section PROGRAM TYPE, indicate In-Patient, Out- Patient, Screening, Detention, Corrections, Probation/Parole, etc. Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone: Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone: Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone:

6 Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone: Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone: Job Title: Employer name and address: Program type & description: Hours per week worked: Dates employed from/to: Supervisor Name and Phone:

7 APPLICATION AFFIDAVIT I, attest and affirm that I am the applicant named in this application and that I have read and completed the contents thereof and to the best of my knowledge and belief, all answers and statements are true and correct and I hereby authorize all persons listed as references in this application to release any information pertinent to my application. I understand and agree that abuse of alcohol and/or other drugs, including prescription drugs, is not acceptable behavior and should circumstances indicate, I may be subject to additional review by the National Association of Forensic Counselors ( NAFC ). I have read, understand and agree with all fee schedules and that all fees are subject to change without notice. I understand and agree that the American College of Certified Forensic Counselors ( ACCFC ) is the certification commission of the NAFC and that NAFC makes all final decisions pertaining to my application, membership and/or certification. I further agree to hold the NAFC and its Certification board members, officers, agents, staff and examiners free from any civil liability for damages or complaints by reason of any action that is within the scope and arising out of the performance of their duties which they may take in connection with this application, the attendant examinations and the grades with respect to any examination, failure of the NAFC to issue me said certificate/wallet card, sanction(s), or any other action(s) taken in connection with my certified and/or non-certified membership in the NAFC ( NAFC membership ) for the duration of my membership in the NAFC. I understand and agree that it is my sole responsibility to read and stay apprised the NAFC Ethical Standards and Code of Conduct, Policies and Procedures, Candidate Handbook, Use of the NAFC Logo Terms, Application Affidavit, and all other terms ( Terms and Conditions ) of the NAFC membership and that all can be downloaded from the NAFC website, or mailed to me by contacting the NAFC office. I understand and agree that all of the above are subject to change without notice and that I am subject to the most current version of all terms and conditions of NAFC membership for the duration of my NAFC membership. I understand and agree that I must submit to proceedings for any alleged violation of any terms and conditions of NAFC membership. I understand and agree that falsification of any NAFC application, documentation submitted, any renewal, workshop proposal, certification upgrade request, re-instatement request, any other information submitted to the NAFC at any time, refusal to submit requested information, refusal to submit to proceedings or fully comply with any investigation will be grounds for denial and/or immediate revocation of NAFC membership and any and all benefits resulting there from. I agree to report within 30 days of my notification any formal charge, complaint, investigation, arrest, or conviction related to a criminal act or ethical violation, or any professionally related civil action, civil litigation, or investigation, brought by any member of the public, including federal, state, or local authorities or agencies, professional organizations, clients, colleagues, or any other member of the public and will keep the NAFC apprised monthly of the status, including any and all corrective actions, judgments, or sanctions issued, or other determinations made. I understand and agree that failure to report any of the above is grounds for immediate suspension, revocation, or other sanction of NAFC membership and any and all benefits resulting there from. I understand and agree that holding my state license active and in good standing, where licensure is required, is mandatory in order to maintain NAFC membership and any suspension or revocation will result in the same by the NAFC and agree to report within 30 days of my notification any formal complaint or charge made against my state license by any member of the public, including federal, state, or local authorities or agencies, professional organizations, client(s), colleagues, or any other member of the public and will keep the NAFC apprised of the status, including any and all corrective actions, judgments, sanctions, or other determinations issued, regardless of whether or not any action has been taken against my license by the state. I understand and agree that failure to report any of the above is grounds for immediate revocation of NAFC membership, suspension or other action, and any and all benefits resulting there from, deemed appropriate by the NAFC. I understand and agree that the NAFC may initiate and pursue action on its own should violation of any terms and conditions of NAFC membership is brought to its attention. I understand that the NAFC may use information collected from my application and membership for non-identifying research and statistical purposes. I agree that if my NAFC certification is suspended or revoked that I will comply with all directives of the NAFC and all certificate(s) and wallet card(s) issued to me remain the property of the NAFC and I agree to return all to the NAFC upon demand in the event of suspension or revocation of the NAFC certification issued to me. I agree to notify the NAFC within 30 days of any change of name, addresses, place of employment, job title, phone numbers, address, or any other information maintained by the NAFC. Signature of Applicant Date

8 Credit Card Authorization Form Visa, MasterCard, Discover only I,, authorize the National Association of Forensic Counselors to charge my credit card in the amount listed below. I attest that I am an authorized user of the below card. Name on Card: Credit Card Number: Billing address of Card: Exp. Date: CVV Code: Amount to Charge: Signature: Date:

9 -Reference Form- Please make copies of this form. Four (4) references forms are required for each application. You are required to provide four (4) professional references with your application All references must be professionals working in your professional field and not related to you. At least one reference must be your immediate supervisor. If you are in Private Practice and do not have an immediate supervisor, then this reference must be someone who has known you professionally for at least three (3) years and hold a minimum of a Master s Degree. Please use the provided reference forms. To Be Filled Out By Applicant: Applicants Name: CCJS- Certified Criminal Justice Specialist CM CFC- Certified Forensic Counselor CM CFI Certified Forensic Interviewer CDVC- Certified Domestic Violence Counselor CM CFSW Certified Forensic Social Worker CSOTS- Certified Sex Offender Treatment Specialist CM Check here if you are seeking the Clinical level for the certification you are applying. Check here if you are exempt from licensure. If checked, you must select reason below and provide proof of exemption with your application: No licensure for my profession, i.e., probation parole, corrections, etc. Exempted from licensure legislatively. Federal/Government Employee, no license required. I,, grant my permission for, to Name of Applicant Name of Reference render an honest appraisal of my ability to competently work in the forensic counseling and/or criminal justice field(s). The National Association of Forensic Counselors and my references are both authorized to release information to each other regarding my appraisal and all parties involved in the certification process are released from civil liability in connection with this appraisal. Applicant s Signature Date To Be Filled Out by Applicant s Reference: Reference Please indicate on this form the following regarding the applicant. Thank you for taking the time to assist the applicant in the certification process. The above information should already be filled out by the applicant prior to you being asked to fill out this form. If it is not filled out, please return to the applicant and ask for the above to be filled out in its entirety before giving your reference. When completed, please return to the applicant in a sealed envelope, or you may send this reference form directly to NAFC: PO Box 8827, Fort Wayne, IN or FAX to I. How long have you known the applicant in a professional capacity? Years Months If the applicant has been employed by your agency, how long? From: To:

10 II. To your knowledge, has the applicant abused or misused alcohol or any other drugs, prescription or otherwise, while rendering professional service and character to their professional field? Yes No If yes, please explain: III. Please comment on the applicant s ability or potential to work in their professional field. IV. Do you know of any reason why this person would not be suitable to work with clients and/or offenders? Yes No If yes, tell us why. V. Relevant to the preceding evaluation: I can recommend this applicant for certification. I cannot recommend this applicant for certification. If you cannot recommend the applicant for certification, please tell us why. If you have any additional comments that you believe will help the Certification Board evaluate the applicant for certification, please list them: Reference Printed Name: Agency: Address: Work Phone: Signature of Reference Date

11 FEE SCHEDULE Minimally, the application fee must accompany your application. If your application is denied, all fees paid excluding the $25.00 application fee will be refunded. Application fee is non-refundable. 1. $25.00 APPLICATION FEE 2. $ EXAMINATION AND FIRST YEAR CERTIFICATION FEE. RENEWAL Annual renewal of your certification is required. For your convenience, bi-annual renewals are available. Please visit our website at for renewal requirements and fees. REQUIREMENTS FOR FORENSIC SPECIALTY CERTIFICATION Non-Clinical Certification Requirements Clinical Level Certification Requirements Bachelors Degree or higher from an accredited educational institution Masters degree or higher from an accredited educational institution State License: active and in good standing, in your profession unless exempted through legislation, or your state does not have licensure in your profession, or you are exempted as a federal or state government employee State License active and in good standing, in your profession unless exempted through legislation, or your state does not have licensure in your profession, or you are exempted as a federal or state government employee Forty (40) hours of formal training in your profession applicable to the certification for which you are applying Forty (40) hours of formal training in your profession applicable to the certification for which you are applying Two years (4,000 hours) of supervised full time professional experience working in your profession in the specialty for which you are applying Three years (6,000 hours) of supervised full time professional experience working in your profession in the specialty for which you are applying Successfully pass the NAFC certification examination Successfully pass the NAFC certification examination Have no misdemeanor or felony arrests for any sexual or violent offense Have no misdemeanor or felony arrests for any sexual or violent offense Have no reprimands or suspensions of your state license or state certification Have no reprimands or suspensions of your state license or state certification Must not have previously held an NAFC certification that has been suspended or revoked Must not have previously held an NAFC certification that has been suspended or revoked EXAMINATION INFORMATION The certification examination is multiple-choice. The scope of the examination covers common-core knowledge in the particular area. There is no specific study guide available. However, there are reading materials that are highly recommended by the NAFC while preparing for the examination. NAFC examinations are scheduled online and are administered at over 500 Comira testing sites throughout the U.S. Because the NAFC holds nationally accredited certification programs, the administration of all examinations must follow the most stringent guidelines. You are not permitted any materials, aids, or writing devices of any kind, electronic or otherwise, with you while taking your examination. SUGGESTED READING MATERIAL FOR EXAMINATIONS: The following are merely suggested reading. The examinations are not based upon any of the below listed readings, and reading any of the below does not guarantee nor suggest that you will pass the examination. All NAFC applicants are expected to be proficient in their field prior to obtaining NAFC certification. FORENSIC COUNSELOR/CRIMINAL JUSTICE SPECIALIST Contemporary Assessment and Treatment of Adult Criminal Justice Clients by Francis J. Deisler, Ph.D. ADDICTIONS Substance Abuse: Information for School Counselors, Social Workers, Therapists, and Counselors (2 nd Edition) by Gary L. Fisher DOMESTIC VIOLENCE When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse by K.J. Wilson

12 SEX OFFENDER TREATMENT SPECIALIST Assessment and Treatment of Sex Offenders: A Handbook by Anthony R. Beech, Leam A Craig, and Kevin D. Browne GAMBLING ADDICTIONS COUNSELOR This Must Be Hell: A Look at Pathological Gambling by Hale Humphrey, Ph.D. JUVENILE SEX OFFENDER TREATMENT SPECIALIST The Juvenile Sex Offender (2 nd Edition) by Howard E. Barbaree, Ph.D., and William L. Marshall GROUP THERAPY SPECIALIST Group Therapy Approaches for Working with Criminal Justice Clients by Francis J. Deisler, Ph.D.