MHRT/Community Guidelines-Appendix D


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[Table of Contents] [ Section 1 ] [ Section 2 ] [ Section 3 ] [ Section 4 ] [ Section 5 ] [ Section 6 ] [ Section 7 ] [ Section 8 ] [ Section 9 ] [ Section 10 ] [ Section 11 ] [ Section 12 ] [ Section 13 ] [ Section 14 ] [ Appendix A ] [ Appendix B ] [ Appendix C ] [ Appendix D ] [ Appendix E ] [ Appendix F ] [ Appendix G ] [ Appendix H ]

APPENDIX D

APPLICATION FOR MHRT/COMMUNITY CERTIFICATION

Please Download this form in one of the following two formats:

MS WORD OR ADOBE ACROBAT

This form may be copied

DIRECTIONS: Please read the May 2008 MHRT/Community Guidelines before completing. Incomplete applications will be returned unprocessed. All applicants must complete Sections I, II, and III. Applicants who have met the certification requirements by earning a pre-approved degree or license must complete Sections IV or V. Official transcripts must be mailed or faxed. E-mails will not be accepted. Applicants who have met the certification requirements through courses, training, workshops, and/or waivers should complete Sections VI and VII. Applications are reviewed in the order they are received. Please allow approximately three weeks for processing. Please note that CFL staff cannot meet with applicants due to the volume of applications.

I. PERSONAL INFORMATION (All Applicants)

First Name:

Last Name:

SSN#:

Mailing Address:

Daytime Phone:

( )

City:

State:

Zip Code:

Date of Birth:

II. WORK INFORMATION: (All Applicants)

If you are currently unemployed, please list NA in this section.

Work Place:

Work Telephone: ( )

Mailing Address:

City:

State:

Zip Code:

III. CHECK CERTIFICATE TYPE: (All Applicants)

FULL MHRT/Community

Provisional MHRT/Community Level A or B

IV. IV. APPLYING FOR FULL MHRT/COMMUNITY THROUGH DEGREE/LICENSE EARNED:

Please refer to the list of acceptable degrees and licenses for full certification in the MHRT/C Guidelines Appendix B. List the degree/license you have earned and attach a copy of the degree (listing the field it is in) or an official transcript showing your degree earned, or a copy of your license.

Degree/License Earned:

From Where:

V. V. APPLYING FOR PROVISIONAL MHRT/COMMUNITY Level A or B THROUGH DEGREE EARNED:

Please refer to the list of acceptable degrees for provisional certification in the MHRT Procedural Guidelines in Appendix C. List the degree you have earned and attach a copy of the degree (listing the field it is in) or an official transcript showing your degree earned.

Degree Earned:

From Where:

APPLICATION FOR MHRT/COMMUNITY CERTIFICATION (cont’d)

This form may be copied

VI. APPLYING FOR PROVISIONAL OR FULL MHRT/COMMUNITY THROUGH COURSES OR WORKSHOPS:

The applicant must complete five courses to earn a Provisional MHRT/C, Level B certificate and courses to earn a Full MHRT/C Certificate. Until January 1, 2009, applicants may choose to complete either Group Process or Vocational Aspects of Disability. As of January 1, 2009 Group Process will not be accepted for MHRT/C credit. If the applicant is substituting workshops in place of courses, the workshop or training must be taught by qualified professional staff and consist of at least 30 hours of training directly related to the course substituted. Please check the courses/workshops you have completed and attach official transcripts or legible photocopies of workshop certificates showing the number of hours completed.

This left column must be completed to earn a Provisional MHRT/C Level B

____ Introduction to Community Mental Health	____ Vocational Aspects of Disability ____ Group Process (not accepted as of 1/1/09)
____ Psychosocial Rehabilitation	____ Substance Abuse with a Dual Diagnosis Component
____ Interviewing and Counseling	____ Sexual Abuse, Trauma, and Recovery
____ Crisis Identification and Resolution	____ Case Management ____ Mental Health & Aging
____ Cultural Competency/Diversity

VII. WORK EXPERIENCE WAIVERS:

Please refer to pages 13-14 of the May 2008 MHRT/C Procedural Guidelines for specific guidelines in reference to waivers. The applicant must submit a signed letter from each of the clinical supervisors. Only one course may be waived for each year of experience. A maximum of five courses may be waived.

	Course(s) to be Waived	Supervisor’s Name and Professional Title
1.
2.
3.
4.
5.

PLEASE NOTE: General letters of reference will not be accepted.

VIII. SUBMIT THIS APPLICATION AND ALL SUPPORTING INFORMATION TO:

MHRT/Community Request
The Center for Learning
45 Commerce Dr., Suite 11
Augusta, ME 04330
Phone: (207) 626-5280 TTY: (207) 626-5282 CFL E-Mail: cfl.muskie@usm.maine.edu

The Center for Learning 45 Commerce Dr. Suite 11 Augusta, ME 04330 Phone: (207) 626-5200 Fax: (207) 626-5022 TTY: (207) 626-5282 cfl-muskie@usm.maine.edu
	Muskie School of Public Service