Focus of practice:Age Groups Childern adolescents Adults Geriatric Disability Groups MH DD SA This information is requested for quality improvement purpose.Licencure/Certification:Lic./Cert type.:Lie./Cert. #Currently Pursuing Lic./Cert:YesNoTypeExpected Date of CompletionOther Cardentials (List): Continuing Education:*** Please attach completed CEU/Training Log:AttachedYesNoSpecialized Training and Expertise: Please Check (or list) the specialties below which represent at least 20% or more of consumers who you have worked with and/or in which you have received specialized training.Consumer RecoveryStrengths BasedPerson Centered PlanningSytems of CareCognitive BehavioralPharmacological Mgt.Child Neglect/AbusePlay TherapyPsychological TestingFamily/Martial TherapyAddiction/ubstance AbuseGrief/Death/DyingMood DisordersAnxiety DisordersPersonality DisordersConduct DisordersAttention Deficit DisordersNeuropsychological TestingVoilence TraumaSexual Abuse (victim)Sexual Abuse (prepetrator)Dually Diagnosed (MH/SA)Crisis InterventionGay/Lesbian AbusesCultural MinoritiesOtherBehavioral Health Level of Care Experience ( if you have 1 or more year(s) in the below levels of care, check applicable item, and years of experience).InpatientResidentialCrisis EmergencyOutpatientCase ManagementIn HomeMedicalNursingCBSClinical SupervisionOther level of Care and Experience:Physicians Only: Copies of Information Must Be Attached)Fedral DEA NumberState State / Province / Region Board CirtificatonBoard Name SpecialtyName of Psychiatric Recidency Training Program Copies of license(s), certifications, and certificate of completion attached. Check here if you are NOT planning to take Board Examinations List Hospitals you have admitting priviledges toCertified Nurse Practitioners Only(Please submit the Following Information) Copy of CNP Certificate for Mental Health Copy of DEA License to prescribe Medications List of Supervising PhsicianLicense#
