APPLICATION PACKET - CCE

1 Board Certified-Telemental health APPLICATION 1 revised January 2017 APPLICATION PACKET This APPLICATION form is interactive. Download the form to your computer to fill it out. 3 TERRA CE WAY GREENSBORO, NC 27403-3660 USA TEL: +1 FAX: +1 The Board Certified TeleMental health Provider (BC-TMH) mark is a trademark of the Center for Credentialing & Education, CCE and NBCC are registered trade and service marks of the National Board for Certified Counselors, Inc. The Center f or Credentialing & Education, Inc. (CCE) values diversity . There are no barriers to credentialing on the basis of gender, race, creed, age, sexual orientation or national origin. TABLE OF CONTENTS Value of the BC-TMH Credential.

2 3 Licensure or Credential Disclosure RequirementApplicants With Credentials or Licenses .. 4 TrainingQualifying Licenses .. 5 Associate or Equivalent Licenses Qualifying Certifications and Credentials .. 6 Eligibility Requirements .. 3 Applying for the BC-TMH .. 7 Maintaining the BC-TMH .. 8 BC-TMH APPLICATION Form .. 9-11 Payment published February 2018 Board Certified-TeleMental health Provider APPLICATION VALUE OF THE CREDENTIAL THE VALUE OF THE BC-TMH CREDENTIAL The value of the BC-TMH credential to credential holders, employers and the public comes from CCE s: Verification of eligibility requirements; Creation and maintenance of peer-reviewed industry training materials;and Ongoing enforcement of industry REQUIREMENTS LICENSURE OR CREDENTIAL Qualifying active and current licensure in the state or country in which the candidate resides orworks.

3 (See list of qualifying licenses on page five).OR Current associate or equivalent licensure under supervision to practice working toward a qualifyingindependent practice license (see page five) in the state or country in which the candidate residesor works. Applicant must have a contract registered with their state board for obtaining experienceunder direct A current, active credential from the list of qualifying credentials and certifications on page six ofthis REQUIREMENT All credential holders and BC-TMH applicants are required to notify the CCE Ethics Department of any of the following matters. Disclosures must be made in writing within 60 days of the individual s knowledge of the complaint or charge, unless you are the applicant and are disclosing a previously concluded matter.

4 In such cases, the disclosure and required documentation must be submitted with your APPLICATION . Required Disclosure Matters: Criminal charge(s)(Note: You do not need to disclose traffic charges unless they involve drugs or alcohol or injuryto a person or property.) Legal action(s) related to business or occupational activities in which you are named as adefendant Grievance(s) by any government entity ( , licensure board) or professional organization ( ,professional credentialing organization) Employment termination(s) due to conduct Probation or removal from any graduate program for reasons unrelated to gradesReview of required disclosed matters are processed in accordance with current CCE policies and procedures, including the CCE Credential Eligibility Policy-Ethics.

5 3 published February Board Certified-TeleMental health Provider APPLICATION Board Certified-TeleMental health Provider APPLICATION published February 4 APPLICANTS WITH CREDENTIALS OR LICENSES If you hold a credential or license from outside the United States, you will need to arrange to have a notarized English translation of the document sent directly to CCE from a translation service. CCE accepts translations completed by CHICLE Language Institute ( ). TRAINING Your APPLICATION must include documentation of successful completion within the last five years of the CCE Telemental health Professional Training Series, including the final comprehensive exam. The following nine content areas are included in the training series: to Telemental Skills for HIPAA Compliance for Telemental health Crisis4.

6 Crisis Planning & Protocols in Video Telemental Practices in Video Telemental health & Using Technology in Telemental Clients/Patients to Telemental Telemental health Settings and Care Coordination10. For information, visit or contact i-lrn at Final exam (submit only this passing score final certificate with BC-TMH APPLICATION )ELIGIBILITY REQUIREMENTS LISW (Licensed Independent Social Worker) LISW-CP (Licensed Independent Social Worker- Clinical Practice)LLP (Limited Licensed Psychologist)LMFT (Licensed Marriage and Family Therapist) LMHC (Licensed Mental health Counselor)LMHP (Licensed Mental health Practitioner) LMSW (Licensed Master Social Worker)LMSW-ACP (Licensed Master Social Worker-Advanced Clinical Practitioner)LP (Licensed Psychoanalyst)LP (Licensed Psychologist) LPA (Licensed Psychological Associate)LPN (Licensed Practical Nurse) LpastC (Licensed Pastoral Counselor)

7 LPC (Licensed Professional Counselor) LPCC (Licensed Professional Clinical Counselor)LPCMH (Licensed Professional Counselor of Mental health ) LPE (Licensed Psychological Examiner) LPP (Licensed Pastoral Psychotherapist)LSATP (Licensed Substance Abuse Treatment Practitioner) LSCSW (Licensed Specialist Clinical Social Worker) LSP (Licensed School Psychologist) LSW (Licensed Social Worker)LVN (Licensed Vocational Nurse) published February 20185 Board Certified-TeleMental health Provider APPLICATION QUALIFYING LICENSES APN (Advanced Nurse Practitioner)DO (Doctor of Ostopathy)LAC (Licensed Associate Counselor)LADAC (Licensed Alcohol and Drug Abuse Counselor) LADC (Licensed Alcohol and Drug Counselor) LAMFT (Licensed Associate Marriage and Family Therapist) LAPC (Licensed Associate Professional Counselor) LASAC (Licensed Associate Substance Abuse Counselor) LCADC (Licensed Clinical Alcohol and Drug Counselor) LCAS (Licensed Clinical Addictions Specialist)LCAT (Licensed Creative Arts Therapist)LCDC (Licensed Chemical Dependency Counselor) LCDP (Licensed Chemical Dependency Professional) LCMFT (Licensed Clinical Marriage and Family Therapist) LCMHC (Licensed Clinical Mental health Counselor) LCP (Licensed Clinical Psychologist) LCP (Licensed Counseling Professional)MD (Medical Doctor) NP (Nurse Practitioner)PA (Physician s Assistant) LCPC (Licensed Clinical Professional Counselor)

8 LCSW (Licensed Clinical Social Worker) LCSW-C (Licensed Certified Social Worker-Clinical) LGSW (Licensed Graduate Social Worker) LICSW (Licensed Independent Clinical Social Worker) LIMFT (Licensed Independent Marriage and Family Therapist) ASSOCIATE OR EQUIVALENT LICENSESPLMHP (Provisionally Licensed Mental health Practitioner) PLPC (Provisional Licensed Professional Counselor) TLLP (Temporary Limited License Psychologist) LPCA (Licensed Professional Counselor Associate) Resident in Counseling/MFT/CSAC Interns in counseling are also eligible to apply for the BC-TMH REQUIREMENTS CFLE (Certified Family Life Educator)CGP (Certified Group Psychotherapist)CHT (Certified Hypnotherapist)CICSW (Certified Independent Clinical Social Worker) CISW (Certified Independent Social Worker) CMFT (Certified Marriage and Family Therapist) CP (Certified Psychologist)CP (Clinical Psychologist) CpastC (Certified Pastoral Counselor)CPC (Certified Professional Counselor)CRADC (Certified Reciprocal Alcohol and Drug Counselor) CRC (Certified Rehabilitation Counselor)CSAC (Certified Substance Abuse Counselor) CSW (Certified Social Worker)CSW (Clinical Social Worker)CSW-C (Certified Social Worker Clinical) DAPA (Diplomate, American Psychotherapy Association) DCC (Distance Credentialed Counselor)DCSW (Diplomate in Clinical Social Work)DOT SAP (Department of Transportation Substance Abuse Professional)

9 DTR (Dance Therapist Registered)MAC (Master Addiction Counselor)MAC (Master Addictions Counselor)MFCC (Marriage, Family and Child Counselor) MFT (Marriage and Family Therapist) MT-BC (Music Therapist-Board Certified) NBCCH (National Board Certified Clinical Hypnotherapist) NBCDCH (National Board Certified Diplomate in Clinical Hypnotherapy)NCC (National Certified Counselor)NCPsyA (Nationally Certified Psychoanalyst)NCSC (National Certified School Counselor)PA (Psychological Associate)PMHNP (Psychiatric Mental health Nurse Practitioner) RAS (Registered Addiction Specialist) RBT (Registered Behavior Technician)RDT (Registered Drama Therapist)REAT (Registered Expressive Arts Therapist)RN (Registered Nurse)RPC (Registered Professional Counselor)RPT (Registered Play Therapist) RPT-S (Registered Play Therapist-Supervisor)SAP (Substance Abuse Professional)SW (Social Worker) QUALIFYING CERTIFICATIONS AND CREDENTIALS 6published February ABPN Diplomate (American Board of Professional Neuropsychology)ABPP (American Board of Professional Psychology)ACS (Approved Clinical Supervisor)ACSW (Academy of Clinical Social Workers)ADTR (Academy of Dance Therapists Registered)APRN (Advanced Practice Registered Nurse)ATR (Registered Art Therapist)ATR-BC (Registered Art Therapist - Board Certified)BCBA-D (Board Certified Behavior Analyst Doctoral) BCBA (Board Certified Behavior Analyst)

10 BCaBA (Board Certified Assistant Behavior Analyst)BCBT (Board Certification in Bereavement Trauma)BCD (Board Certified Diplomate in Clinical Social Work) BCDT (Board Certification in Disability Trauma) BCDV (Board Certification in Domestic Violence)BCETS (Board Certified Expert in Traumatic Stress)BCFT (Board Certification in Forensic Traumatology)BCIT (Board Certification in Illness Trauma)BCMVT (Board Certification in Motor Vehicle Trauma)BCPM (Board Certification in Pain Management)BCRT (Board Certification in Rape Trauma)BCSA (Board Certification in Sexual Abuse)BCSCR (Board Certification in School Crisis Response) BCSM (Board Certification in Stress Management)BCUCR (Board Certification in University Crisis Response) CAC (Certified Addictions Counselor) CAC (Certified Alcoholism Counselor) CADAC (Certified Alcohol and Drug Abuse Counselor) CADC (Certified Alcohol and Drug Counselor)CAMF (Certified Anger Management Facilitator) CAP (Certified Addictions Professional)CART (Certified Anger Resolution Therapist)CAS (Certified Addiction Specialist)CASAC (Certified Alcohol and Substance Abuse Counselor) CBT (Certified Bioenergetic Therapist) CCADC (Certified Clinical Alcohol and Drug Counselor) CCDP (Certified Chemical Dependency Professional) CCHT (Certified Clinical Hypnotherapist) CCPT (Certified Clinical Pastoral Therapist) CCMH (Clinical Counselor in Mental health )