Fillable Cbhi Licensure Reimbursement Application (Commonwealth of Massachusetts)

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Cbhi Licensure Reimbursement Application (Commonwealth of Massachusetts)

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The Cbhi Licensure Reimbursement Application (Commonwealth of Massachusetts) form is 2 pages long and contains:

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  • 5 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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6 | Page
Application
Part I. Applicant Information
Staff Name:
Email:
Street Address
(Home):
City/Zip Code:
Telephone:
CBHI Service/Role:
Supervisor Name:
Supervisor phone:
Supervisor Email:
CBHI Site Location
(City/Town):
Which independent license do you have?
This program is only for IHT, ICC, MCI, and IHBS staff who have obtained
their independent licensure (including LICSW, LMHC, LMFT, and
Psychologists) after 7/1/19. Staff seeking an LCSW are not eligible.
All applications must include a copy of your independent license.
LICSW
LMFT
LMHC
Psychology
Other:
When did you receive your independent license?
Successful applicants must have received their independent license on or after July 1, 2019.
Part II. Agency Information
Provider Agency Name:
Street Address:
City/Zip Code:
Telephone:
CEO:
Part III. Letter of Support from Chief Executive Officer/Executive Director
A letter stating the organization’s acknowledgement of staff’s application for funding. Employer should explicitly
acknowledge the employee’s guarantee to maintain current employment for at least six months following the
date of independent licensure. This letter should be on agency letterhead and signed by the Chief Executive
Officer/Executive Director of the organization. This must be included in order for the application to be reviewed.
7 | Page
Part IV. Employment Commitment
If I am to receive funding for licensure support, I, (insert name), agree to
maintain my current employment for at least six months following the date I received my independent license.
I realize that failure to maintain this commitment will result in the need to repay the funds allotted to me.
Signed:
Date:
Part V. Licensure Verification
Proof that you obtained independent licensure on/after 7/1/19. A copy of your independent license must be
included in order for the application to be reviewed. Note that proof of passing the exam does not count. You
must have already obtained your license to qualify for reimbursement.
Qu
estions can be directed to Amy Horton at 617-266-5657 ext. 122 or ahorton@tacinc.org
. Completed
application packets should be emailed to Amy Horton, ahorton@tacinc.org.
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Cbhi Licensure Reimbursement Application (Commonwealth of Massachusetts)

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Completed 18 July 2020

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