Fillable Certified Behavioral Health Case Manager Provisional Upgrade On-the-Job

Fill Online, Printable, Fillable, Blank Certified Behavioral Health Case Manager Provisional Upgrade On-the-Job Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Certified Behavioral Health Case Manager Provisional Upgrade On-the-Job

On average this form takes 11 minutes to complete

The Certified Behavioral Health Case Manager Provisional Upgrade On-the-Job form is 5 pages long and contains:

  • 1 signature
  • 14 check-boxes
  • 33 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Certified Behavioral Health Case Manager
Provisional Upgrade On-the-Job Supervision Verification Form
CBHCMP Upgrade On-the-Job Supervision Verification Form Florida Certification Board (FCB)
Effective Date: May 2019
DIRECTIONS
This form allows for one qualified supervisor to document on-the-job supervision hours as required for the CBHCM
Provisional Upgrade credential. Provide a separate form and instructions to each qualified supervisor who will
document supervision for certification purposes. FCB has supervision documentation templates posted online that may
be used if needed.
All information must be TYPED. Handwritten forms will be denied. This is a two-part form.
• Part On
e is completed by the applicant and provided to the qualified supervisor.
• Part Two is completed by the qualified supervisor and provided to FCB by mail, email or fax (see below).
Upo
n completion, please submit the form directly to the FCB. On-the-Job Supervision Verification Forms will not be
accepted from the applicant.
Mail:
Florida Certification Board
Email:
Certification Specialist’s email or
Attn: Certification Operations
admin_assist@flcertificationboard.org
1715 South Gadsden Street
Fax:
850-222-6247
Tallahassee FL 32301
Subject Line:
On-the-Job Supervision (applicant name)
REQUIREMENT
Policy Standard
Supervision focuses on improved client care and improved job performance. The purpose of
supervision is to teach counselors how to promote client welfare and increase their skills
and knowledge in order to effectively treat their client base. Supervision for certification
purposes can be individual, one-on-one supervision and/or observation of skills OR group
supervision/case staffings. At least 50% of the hours of supervision must be individual, one-
on-one supervision and/or observation skills. No more than 50% of the required hours of
supervision may be in a group setting. See FCB's website at www.flcertificationboard.org
for additional details and guidance.
CBHCM Description
A designation is for individuals who supervise those who provide direct targeted case
management services to adults and/or children with mental health conditions, substance
use disorders, and/or those involved in the child welfare system who require behavioral
health case management services.
(Co
ntinued on next page)
Certified Behavioral Health Case Manager
Provisional Upgrade On-the-Job Supervision Verification Form
CBHCMP Upgrade On-the-Job Supervision Verification Form Florida Certification Board (FCB)
Effective Date: May 2019
Qualified Supervisor
Definition
A qualified supervisor must be current and fall within one of the following designations:
•
A physician or physician’s assistant licensed under Chapters 458 or 459, Florida
Statutes
• A professional licensed under Chapters 490 or 491, Florida Statutes
• An Advanced Registered Nurse Practitioner licensed under Part 1 of Chapter 464,
Florida Statutes
• A Master’s Level Certified Addiction Professional (MCAP)
• A Certified Addiction Professional (CAP)
• A Certified Behavioral Health Case Manager Supervisor (CBHCMS)
On-the-Job
Supervision
Requirement
50 hours of on-the-job supervision of the applicant’s performance of core competencies.
The 50 h
ours are allocated across performance domains as follows:
1. Engagement and Assessment (initial and ongoing): 10 hours
2. Service Planning and Development (initial and ongoing): 10 hours
3. Coordination, Linkage and Monitoring: 10 hours
4. Documentation: 10 hours
5. Professional, Legal and Ethical Responsibilities: 10 hours
For certification purposes, the FCB benchmarks reasonable and achievable supervision at the
rate of 3 hours per week/156 hours per year.
Elig
ible on-the-job supervision occurred within the last 5 years.
PERFORMANCE DOMAIN CATEGORIES
Minimum of 10 hours must be completed in each performance domain listed below.
ENGAGEMENT AND ASSESSMENT (initial and ongoing): Supervision in this domain is directly related to observing and
providing feedback to the applicant as he or she performs tasks such as engaging the client in services and conducting
an assessment to determine the client’s individual strengths and needs.
SERVICE PLANNING AND DEVELOPMENT (initial and ongoing): Supervision in this domain is directly related to
observing and providing feedback to the applicant as he or she performs tasks such as translating the results of
assessment activities into functional services and tasks that address immediate, short-term, long-term and ongoing
needs.
COORDINATION, LINKAGE AND MONITORING: Supervision in this domain is directly related to observing and
providing feedback to the applicant as he or she performs tasks such as assisting the client to implement the case
management plan and monitoring the ongoing effectiveness of the plan in meeting client outcomes.
(C
ontinued on next page)
Certified Behavioral Health Case Manager
Provisional Upgrade On-the-Job Supervision Verification Form
CBHCMP Upgrade On-the-Job Supervision Verification Form Florida Certification Board (FCB)
Effective Date: May 2019
DOCUMENTATION – 10 hours: Supervision in this domain is directly related to observing and providing feedback to
the applicant as he or she documents service provision according to federal, state and agency requirements and best
practices.
PROFESSIONAL, LEGAL AND ETHICAL RESPONSIBILITIES – 10 hours: Supervision in this domain is directly related
to observing and providing feedback to the applicant as he or she performs tasks across all domains in a manner
that follows generally accepted legal, ethical, and professional standards.
SUPERVISOR REQUIRED DOCUMENTATION
A qu
alified supervisor must maintain documentation of supervision, copies of which may be requested by Certification
Staff at any time. Documentation must include the following minimum information:
a. Supervisee name, current position and credential sought.
b. Date of supervision, start and end time of supervision, and number of supervision hours accrued.
c. Supervisor name and title.
d. Methods of supervision (individual, group, observation, review clinical documentation).
e. Summary of supervision offered during session.
f. Signature of both Supervisee and Supervisor
Documentation does not need to be submitted with this verification form. FCB ha
s supervision documentation templates
posted online that may be used if needed.
Certified Behavioral Health Case Manager
Provisional Upgrade On-the-Job Supervision Verification Form
CBHCMP Upgrade On-the-Job Supervision Verification Form Florida Certification Board (FCB)
Effective Date: May 2019
All
information must be typed. Handwritten forms will be denied.
Part 1: To be completed by the applicant prior to providing to the qualified supervisor for completion.
Applicant Information: Please list the position you held for which you are requesting documentation of on-the-job
supervision by a qualified supervisor. Report employment dates in the following format: MM/DD/YYYY to
MM/DD/YYYY. Use a separate form for each qualified supervisor documenting clinical on-the-job supervision.
Applicant Name:
Employer:
Type of Position: Full-time Part-Time
Position Title:
Immediate Supervisor:
Part 2: To be completed by the applicant’s qualified supervisor only.
Section A: Qualified Supervisor Contact Information
Last Name:
First Name:
Title:
Employer:
Email Address:
Business Phone:
Work Address:
City:
State:
Zip Code:
County:
Section B: Supervision Attestation
I am a qualified supervisor because I am:
A physician or physician’s assistant licensed under Chapters 458 or 459, F.S.
A professional licensed under Chapters 490 or 491, F.S.
An Advanced Registered Nurse Practitioner licensed under Part 1 of Chapter 464, F.S. and meeting the
Board of Nursing requirements for a ARNP designation.
A MCAP, CAP or CBHCMS credentialed through the Florida Certification Board.
Copy of qualifying credential or license for the qualified supervisor is attached. Yes No
Certified Behavioral Health Case Manager
Provisional Upgrade On-the-Job Supervision Verification Form
CBHCMP Upgrade On-the-Job Supervision Verification Form Florida Certification Board (FCB)
Effective Date: May 2019
Section B: Supervision Attestation Continued
Domain Category – Please see Page 2 of On-the-Job Supervision
Verification Form for instructions
Individual Supervision
Number of Hours
Group Supervision
Number of Hours
ENGAGEMENT AND ASSESSMENT (initial and ongoing)
SERVICE PLANNING AND DEVELOPMENT (initial and ongoing)
COORDINATION, LINKAGE AND MONITORING
DOCUMENTATION
PROFESSIONAL, LEGAL AND ETHICAL RESPONSIBILITIES
TOTAL HOURS PER CATEGORY:
TOTAL HOURS OF ON-THE-
JOB SUPERVISION EARNED:
(No more than 50% of the total required hours may be in a group setting)
Type of Position Supervised Full-Time
Part-Time
Time period during which supervision was provided:
From: To:
I have read and understand the on-the-job supervision requirements for Certified Behavioral Health Case Manager
(CBHCM) certification. I provided the above on-the-job supervision to the applicant and maintain supervision records
supporting my attestation according to agency protocol. I consent to an audit of such records if requested.
Yes No
As a qualified supervisor, do you have any concerns about the applicant's ability to competently perform as a Certified
Behavioral Health Case Manager? Yes* No
*If yes, the FCB will contact you for additional information, which may result in non-acceptance of these on-the-job
supervision hours to meet certification requirements.
I provided on-the-job supervision of the applicant as he or she performed behavioral health case management
services at the level expected of a Certified Behavioral Health Case Manager. Yes
No
By my signature, I attest that the above material is true to the best of my knowledge.
Qualified Supervisor’s Signature
(FCB accepts manual and electronic signatures)
Date
0.00
0.00
0.00
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Certified Behavioral Health Case Manager Provisional Upgrade On-the-Job

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document