Fillable BC-TMH US Application Form (CCE Global)

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BC-TMH US Application Form (CCE Global)

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Updated July 2020
1Board Certied-TeleMental Health Application Packet
Application Packet
This application form is interactive.
Download the form to your computer to ll it out.
3 TERRACE WAY
GREENSBORO, NC 27403-3660 USA
TEL: +1 336.482.2856 FAX: +1 336.482.2852
cce-global.org credentialinfo@cce-global.org
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 for 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.
Board Certified-TeleMental Health
PROVIDER
™
CENTER FOR
CREDENTIALING
&
EDUCATION
Updated July 2020
2Board Certied-TeleMental Health Application Packet
TABLE OF CONTENTS
Board Certified-TeleMental Health
PRO VIDER
Value of the BC-TMH Credential
Eligibility Requirements
Applying for the BC-TMH
Maintaining the BC-TMH
BC-TMH Application Form
Payment Voucher
3
3
5
6
7–9
10
Updated July 2020
3Board Certied-TeleMental Health Application Packet
WHY THE BC-TMH CREDENTIAL?
The BC-TMH helps credential holders demonstrate their skills, knowledge, and credibility to their employers
and the public. CCE designed the credential to give mental health professionals a mark of distinction, showing
their clients that they have the training and ability to provide telemental health services. Our commitment to the
safe and eective practice of telemental health, reliance on peer-reviewed training materials, and the rigorous
enforcement of industry standards provides the solid ground that gives the BC-TMH its value.
LICENSURE OR CREDENTIAL
• Qualifying active and current mental health licensure in the state or country in which the candidate
resides or works.
OR
• Current associate or equivalent mental health licensure under supervision to practice working toward
a qualifying independent practice license in the state or country in which the candidate resides or
works. Applicant must have a contract registered with their state board for obtaining experience
under direct supervision.
DISCLOSURE 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. 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 trac charges unless they involve drugs or alcohol or injury to a
person or property.)
• Legal action(s) related to business or occupational activities in which you are named as a defendant
• Grievance(s) by any government entity (e.g., licensure board) or professional organization (e.g.,
professional credentialing organization)
• Employment termination due to conduct
• Probation or removal from any graduate program for reasons unrelated to grades
Review of required disclosed matters are processed in accordance with current CCE policies and procedures,
including the CCE Credential Eligibility Policy-Ethics.
VALUE OF THE CREDENTIAL
ELIGIBILITY REQUIREMENTS
Updated July 2020
4Board Certied-TeleMental Health Application Packet
APPLICANTS WITH NON-U.S. 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 (chi-cle.com).
APPROVED TRAINING PROGRAMS AND TELEMENTAL HEALTH EXAM
All applicants must successfully complete the approved telemental health training and pass the TMH exam.
Approved trainers are listed on the website at Required Training. Applicants who have completed the training
and need free TMH exam access must submit training certicate(s) with the BC-TMH application packet.
Examinees who have already passed the TMH exam must submit a copy of the nal TMH exam certicate
dated within the previous two years.
For more information, visit cce-global.org/credentialing/bctmh/training.
Updated July 2020
5Board Certied-TeleMental Health Application Packet
APPLYING FOR THE BC-TMH
THE APPLICATION PROCESS
APPLICATION PROCESSING TIMELINE
General timeline once your application is received:
*All applications are reviewed in the order received. If your application requires additional review or if additional
information is needed to complete the review, your application review will be delayed.
If you have questions regarding the BC-TMH application or credential, contact CCE:
Telephone: +1 336.482.2856
Fax: +1 336.482.2852
Email: credentialinfo@cce-global.org
For information about other opportunities with CCE, visit cce-global.org.
SUBMITTING YOUR APPLICATION
You have three options for submitting your application:
Mail: CCE; PO Box 63223; Charlotte, NC 28263-3223
Fax: +1 336.482.2852
Email: credentialinfo@cce-global.org
• Please be sure to include the application fee. This fee is nonrefundable and nontransferable.
• All application materials must be submitted in English.
• All application materials should be submitted to CCE in one packet.
• If you are mailing your application, be sure to make copies of all your application materials before
submitting the originals to CCE.
APPLYING FOR THE BC-TMH
Processing Step Business Days
Payment processing and account setup 3–5
Data entry and application review* 12–13
Total Processing Time: 15–18
Updated July 2020
6Board Certied-TeleMental Health Application Packet
BC-TMH CREDENTIAL APPLICATION AND MAINTENANCE FEES
Fees are nonrefundable and nontransferable.
Application fee: $150 U.S.
Annual maintenance fee: $45 U.S.
To maintain the BC-TMH, credential holders must:
Stay current in the eld: Telemental health is a dynamic eld. Therefore, BC-TMH credential holders should
stay current by obtaining four continuing education (CE) clock hours every year, with a minimum of 20 CE
clock hours specic to telemental health during every ve-year recredentialing period. CCE conducts random
audits yearly. To maintain a record, please download a continuing education log. You must also retain copies
of your certicates of completion (dates, titles, providers, hours awarded, approver required) or other approved
activity verication. For more information, please visit the continuing education section on our website.
Disclose: Each year with renewal, the credential holder attests to compliance with CCE policies and
procedures, including disclosure about any criminal, legal, or disciplinary related matters. However, if
something happens during the year, do not wait to disclose. CCE requires all applicants and credential holders
to disclose any criminal, legal, or disciplinary related matters within 60 days of the occurrence of any such
matter, unless otherwise specied to CCE in writing.
Update information and remit annual fees: Annual fees are $45 and due in your BC-TMH anniversary
month. In order to receive notications, please keep your contact information with CCE current, including
email. Payment indicates you agree to comply with CCE policies and procedures, including adherence to the
BC-TMH disclosure requirements.
Upgrade associate or equivalent licensure status: If you were under supervision for licensure at the time of
initial application, you must submit a copy of your active full licensure during your rst ve-year recredentialing
period. Alternatively, you can submit proof of an eligible current, active status credential as described under
the BC-TMH requirements. Failure to verify full licensure or eligible credential will result in the expiration of
your BC-TMH credential. To regain active status, you will be required to submit a reinstatement application and
meet all reinstatement requirements.
Recredential: At the end of each ve-year period, the recredentialing agreement must be reviewed, signed,
dated, and then submitted with the annual fee. CCE may select you for an audit and require you to submit
your CE documentation. Payment indicates you agree to comply with CCE policies and procedures, including
adherence to the BC-TMH disclosure requirements.
REINSTATEMENT REQUIREMENTS
If your BC-TMH becomes inactive or expires, you will need to take the following steps:
1. Submit a completed BC-TMH Reinstatement Application
2. Pay the BC-TMH reinstatement fee ($50)
3. Pay any past-due fees
4. If inactive, document four continuing education clock hours per year of your credentialing period in
which you were inactive (if not taken during the inactive period, must be obtained prior to requesting
reinstatement)
5. Review and sign the Applicant Agreement and Release Authorization
MAINTAINING THE BC-TMH
Updated July 2020
7Board Certied-TeleMental Health Application Packet
PLEASE FILL OUT ELECTRONICALLY OR PRINT CLEARLY
1. First Name, MI:
Last Name:
Previous Name(s):
2. Street Address:
City, State/Province:
3. ZIP/Postal Code, Country:
Home Telephone: Business Telephone:
Fax:
4. Email:
Check here if you do NOT want your contact information shared with continuing education providers.
5. Gender: Male
Female Other
6. Date of Birth (mm/dd/yyyy):
Ethnic Origin (optional—for statistical purposes only):
African American Native American Asian Caucasian
Hispanic/Latino Native Hawaiian Multiracial Other
7. I am interested in volunteering for marketing eorts standards development.
8. I am applying for this credential based on (choose one):
Qualifying current, active mental health licensure
Qualifying current, active associate or equivalent mental health licensure under supervision to practice
Qualifying current, active mental health credential or certication
9. How did you hear about the BC-TMH?
10. Licenses/Credentials (A copy of license/credential required except for current NCC, ACS, and DCC.)
Under Supervision?
State License/Certicate Type Yes/No License/Certicate Number Issue Date Expiration Date
11. I am applying with the following training or TMH exam verication:
Final TMH Exam certicate dated within prior two years (completed after the Telemental Health Professional
Training Series).
Active DCC with certicates of approved TMH training for module content three and ve.
Training certicate(s) of an in-person, webinar, or online approved course.
APPLICATION FORM
page 1
Board Certified-TeleMental Health
PROVIDER
FOR OFFICE
USE ONLY
REF.#1:
BATCH #1:
DATE:
AMOUNT:
Updated July 2020
8Board Certied-TeleMental Health Application Packet
Applicant’s Name: Date:
12. Disclosure Requirements:
BC-TMH credential holders are required to abide by the ethical guidelines established by their licensing or
credentialing board(s). Additionally, whether you are an applicant or credential holder, you are required to
disclose any of the following types of matters to CCE:
• Criminal charge (Note: You do not need to disclose trac charges unless they involve drugs or
alcohol or injury to person or property.)
• Legal action related to business or occupational activities in which you are named as a defendant
• Grievance by any government entity or professional organization
• Employment termination due to conduct
• Probation or removal from any graduate program for reasons unrelated to grades
Written disclosures must be received within 60 days of you becoming aware of the required disclosure, unless
you are an applicant and are disclosing a previously concluded matter. In such cases, the disclosure and
required documentation must be submitted with your application.
13. Attestation:
(Please respond to each statement below)
1. Have you ever been or are you currently charged with a criminal oense?
2. Have you ever been or are you currently a defendant in any type of legal action
related to your business or occupational activities?
3. Have you ever been or are you currently the subject of any complaint matter or
disciplinary review by any government entity or professional organization?
4. Have you ever been terminated or discharged from employment for conduct reasons?
5. Have you ever been placed on probation or removed from any graduate program in
which you were enrolled for reasons unrelated to grades?
If you answered “YES” to any of the above questions, you must include a complete, detailed explanation
related to the response. You must also provide copies of relevant documentation, such as copies of the
complaint, pleadings, and compliance with nal orders.
Place these materials in a sealed envelope marked “Attention: CCE Ethics Department” and return with your
application.
Failure to provide required information will delay the processing of your application.
APPLICATION FORM
page 2
Board Certified-TeleMental Health
PROVIDER
Yes No
Yes No
Yes No
Yes No
Yes No
Updated July 2020
9Board Certied-TeleMental Health Application Packet
Applicant’s Name: Date:
14.
Application Agreement & Release Authorization
All information I provided in this application, including supporting documentation, is accurate to the best of my
knowledge. If I have knowledge of any changes concerning my responses in this application, including my
responses in the Attestation above, I agree to report this to CCE in writing within 60 days.
I agree that CCE has the right to contact any person or organization regarding this application, and I authorize
the release of any information requested by CCE to verify the accuracy. I understand that all application
materials become the property of CCE and will not be returned.
I understand that credentialing through CCE depends upon my fulllment of all required criteria and compliance
with CCE policies including the CCE Credential Eligibility Policy-Ethics, and the CCE credential mark and
trademark use policy. I understand that credentialing does not create membership in CCE. I understand that
CCE credentialing is personal to me and may not be transferred to another individual or group.
I understand that professional biographical and credential data is considered public information and will be
made available in response to public inquiries. I agree that data related to my participation in CCE credentialing
may be used for research and statistical purposes.
I recognize that any credential granted by CCE does not represent licensure or other authorization to practice
business activities for a fee. I release CCE from all liability and claims arising from any professional activity.
Applicant Signature Date (mm/dd/yyyy)
(please print and sign)
APPLICATION FORM
page 3
Board Certified-TeleMental Health
PROVIDER
click to sign
signature
click to edit
Updated July 2020
10Board Certied-TeleMental Health Application Packet
CURRENT APPLICATION FEES
Application fee: $150
• All fees must be paid in U.S. dollars and are nonrefundable.
• Once your payment has been processed, CCE will review
your application within approximately 18 business days.
• You will be notied of your status and informed if further
information is needed.
• CCE holds applications open for three years. During that time,
applicants have the opportunity to rectify any deciencies.
METHOD OF PAYMENT
PLEASE FILL OUT ELECTRONICALLY OR PRINT CLEARLY
Applicant’s Name:
Telephone Day: Evening:
Enclosed is a check or money order payable to CCE in the amount of $150 U.S.
Please charge the credit card listed below in the amount of $150 U.S.
Card VISA MasterCard
American Express
Name on Card:
Card Number: Expiration Date:
Verication Code (from back of card):
Cardholder Signature: Date:
(please print and sign)
If you are mailing your application, be sure to make copies of all your application materials before
submitting the originals. CCE cannot return any forms or documents to you or to a third party.
PAYMENT VOUCHER
Board Certified-TeleMental Health
PROVIDER
Submit your application by only one of the following methods:
• By mail: CCE; P.O. Box 63223; Charlotte, NC 28263-3223
• By fax: +1 336.482.2852
DOCUMENT CHECKLIST
Application
Copy of professional license
Copy of TMH exam certicate
OR
DCC submitting modules 3 and 5
OR
Copy of nal TMH training certicate(s)
Check this box and email your application to credentialinfo@cce-global.org. Please note that we cannot take
payment via email. We will reach out to you via email with instructions after you email your application.
If you wish to submit this application via email, DO NOT complete the credit card information on this page.
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BC-TMH US Application Form (CCE Global)

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Completed 13 September 2020

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