Fillable Certified Behavioral Health Case Manager Provisional Upgrade Work

Fill Online, Printable, Fillable, Blank Certified Behavioral Health Case Manager Provisional Upgrade Work 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 Work

On average this form takes 6 minutes to complete

The Certified Behavioral Health Case Manager Provisional Upgrade Work form is 2 pages long and contains:

  • 0 signatures
  • 3 check-boxes
  • 23 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 Work Experience Verification Form
CBHCMP Upgrade Work Experience Verification Form Florida Certification Board (FCB)
Effective Date: February 2019
DIRECTIONS
This form allows for one employer to document work hours as required for the CBHCM Provisional Upgrade credential.
Provide a separate form to each employer who will document experience for certification purposes.
All information must be TYPED. Handwritten forms will be denied. This is a two-part form.
• Part
One is completed by the applicant and provided to the employer.
• Part Two is completed by the employer and provided to FCB by mail, email or fax (see below).
Upon completion, please submit the form and supporting documentation directly to the FCB. Work Experience 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:
Work Experience Verification (applicant name)
REQUIREMENT
CBHCM Description
A designation for individuals 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.
Related Work
Experience
Requirement
2,000 hours of work experience providing direct behavioral health case management services
to adults or children in the fields of mental health, substance abuse or child welfare. One
year of full-time employment at 40-hours per week, equals 2,080 hours.
Wo
rk experience must be directly related to the core competencies of the credential and
must have occurred within the last 5 years.
Vo
lunteer experience and non-clinical internships are not eligible for certification purposes.
Supporting
Documentation
Attach a position description that directly relates to the core competencies of the credential.
Must be on agency letterhead.
Certified Behavioral Health Case Manager
Provisional Upgrade Work Experience Verification Form
CBHCMP Upgrade Work Experience Verification Form
Florida Certification Board (FCB)
Effective Date: February 2019
A
ll information must be typed. Handwritten forms will be denied.
Part 1: To be completed by the applicant prior to providing to employer for completion.
verification by your employer. Report employment dates in the following format: MM/DD/YYYY to MM/DD/YYYY. Use a
Part 2: To be completed by the employer’s personnel officer or designee only.
Section A: Verifier’s Contact Information
Last Name:
First Name:
Title:
Employer:
Email Address:
Business Phone:
Work Address:
City:
State:
Zip Code:
County:
Section B: Experience Attestation
I have read and understand the on-the-job experience requirements for Certified Behavioral Health Case Manager
(CBHCM) certification. The following information can be verified by employment records maintained by the agency. I
consent to an audit of such records if requested. Yes No
Applicant’s Position Description Attached: Yes Type of Position: Full-Time Part-Time
Applicant’s Employment Dates (use MM/DD/YYYY format): From: To:
Average number of hours per week providing related services:
By my signature, I attest that the above material is true to the best of my knowledge
Verifier’s Signature
(FCB accepts manual and electronic signatures)
Date
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 Work

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