Fillable Criteria For Batterer Intervention Professional (BIP) (Missouri Credentialing Board)

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Criteria For Batterer Intervention Professional (BIP) (Missouri Credentialing Board)

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Revised August 2019 BIP Application 1
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Criteria For Batterer Intervention Professional (BIP)
I. BIP Criteria
HSE/HS Diploma or higher
24 hours of direct facilitation or co-facilitation of Batterer Intervention groups within the last 10
years
3 contact hours of live ethics training (not online or home study)
Complete MCB TIP 25 Self-Study Course (Contact MCB Office to obtain course)
50 contact hours of Batterer Intervention related training (see P. 7)
CHECK LIST FOR BIP APPLICATION
1. You have submitted a $75.00 check or money order with this application or have provided your
credit/debit card information on page 4 of this application packet. Applications will not be
reviewed until payment is received.
2. You have completely filled out the application.
3. You have signed the Ethics Code page of this application.
4. You have filled out the Family Care Safety Registry Worker Registration Form and included the form
with your packet. If your agency has conducted a FCSR background check on you within the last 30
days, you may submit the results to help expedite the application process.
5. An appropriate person has completed and signed the BIP Verification Form.
6. You have included proof of 3 contact hours of live ethics training.
7. You have included proof of completing the MCB TIP 25 Self-Study course.
8. You have included proof of 50 contact hours of Batterer Intervention related training. (See page 7)
9. You have included the completed BIP reference form.
10. The appropriate High School/HSE or College transcripts were included.
11. Check the Professional Search on the MCB web site homepage at www.missouricb.com. Type in
your last name. If your application is complete, your credential information will be displayed and
you should have received your welcome letter and certificates by e-mail.
Revised August 2019 BIP Application 2
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Application Instructions:
1. Requirements to receive this credential are subject to change without notice. Please make sure you
are submitting the most recent application packet. If you are unsure, contact the MCB office.
2. The application must be typed or neatly printed.
3. Please keep a copy of all materials submitted for your records.
4. FEES: The total fee if applying for the BIP is $75.00. You may pay either by check, money order, or
by providing credit card information on page 4 of this application packet. Applications will not be
reviewed until payment is received.
5. Please be aware that should your application be reviewed and additional information is requested,
you will have 90 days to provide the requested information. Failure to do so will result in your
application expiring without being approved.
6. All fees are non refundable. If your application is denied or expires, fees will not be refunded.
7. If your application is denied, you may contact the MCB office staff for instructions on how to appeal
the denial of your application.
8. All materials submitted to the MCB office become property of the MCB.
9. The applicant must currently reside and/or be employed in the State of Missouri at least 51% of the
time. The only exception to this is applicants living and working in a state that is not a member of
the International Certification and Reciprocity Consortium.
10. If at any time during the credentialing process, a question arises about an applicant’s moral character,
reputation for honesty, integrity, or professionalism, the Board may either deny the application at that
time or place the application on hold until an investigation has been done and a decision made
regarding the question brought up.
11. The BIP credential renews every 2 years and requires 36 hours of relevant educational training with 6
of those hours being live ethics. Depending on when you are issued your BIP credential and
depending on other MCB credentials held, the first renewal period may be more or less than 2 years.
Please read your initial credential letter carefully.
12. Please remember that it is your responsibility to keep the MCB office informed of any personal
informational changes such as address and phone number changes. If you fail to notify us of changes,
you will be responsible for any material that is mailed to the wrong address and may have to pay a
fee to have the material sent again.
13. Please mail your application to the MCB. Please do not fax or e-mail your application.
Revised August 2019 BIP Application 3
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to
those seeking a MCB credential.
1. No individual currently under any type of court supervision can apply for a MCB credential. Please
wait until you are completely free from court supervision before applying.
2. The following items disqualify an individual from ever being credentialed with the MCB:
A. Is listed on the Department of Mental Health disqualification registry
B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept.
of Social Services
C. Any crime against a minor
D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any
of the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only
disqualify an applicant if the crime (s) were a felony. Please view information about Section
630.170, RSMo on the MCB web site www.missouricb.com under the Disqualifying Crimes
Link.
3. If an individual has applied for and been given an exception from the Department of Mental Health,
the individual may apply for a MCB credential. Please send in proof of exception with your
application.
Revised August 2019 BIP Application 4
APPLICATION
FOR
Batterer Intervention Professional (BIP)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 2
nd
Floor
JEFFERSON CITY, MISSOURI 65101
TELEPHONE: (573) 616-2300
WEB SITE: www.missouricb.com
EMAIL: help@missouricb.com
Please Mark Credit Card Type:
1. Visa _____________
2. MC _____________
3. Discover _____________
CC Expiration Date: _____/_______
Credit Card #: __________-______________-______________-____________
Credit Card 3 Digit Verification Code: ________________________________
Revised August 2019 BIP Application 5
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Applicant’s Name:
________________________________________________________________________
First Middle Last Name Suffix (Jr., II)
_________________________________________________________________________________________________________
Maiden Other Names Used
Current Home Address:____________________________________________________________________________
Street/PO Box Apt. #
____________________________________________________________________________________________________________________
City State Zip County
Home Telephone: ________/_______________ SSN:__________-________-_____________
Work Telephone:
________/_______________, Ext. ________ Cell Number: ________/_________________
E-mail Address:
___________________________________________________________________________
SEX: ____M ____F BIRTH DATE: _____/_____/____________
Are you currently or have you been credentialed or licensed as a Substance Use Disorder Professional by the MCB or
any other state or organization? ______Yes ______No
If yes, which state/organization and when? ____________________________________________________________
What is the type of credential/license held with the other state/organization?
_______________________________________________________________________________________________
Have you ever been ARRESTED and/or CONVICTED of a felony? ____Yes ____No
If yes, please go to the www.missouricb.com website, print off the “Felony Offense Form”, fill out the form and
submit with your application. If you were convicted of a felony listed in Section 630.170 RSMo (view
www.missouricb.com; Disqualifying Crimes link), you may not apply for this credential without an exception from
the Department of Mental Health.
Have you ever knowingly been contacted by a Children’s Division employee regarding a CHILD ABUSE and/or
CHILD NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.missouricb.com website, print off the “Child Abuse/Neglect Statement”, fill out the
form and submit with your application. In addition, please contact the Children’s Division at 573-751-4920 and
request a report of the incident to include with this application.
Revised August 2019 BIP Application 6
Education/Degree Information
Please mark your highest level of education completed:
1. High School Diploma/HSE: _____
2. Addiction Certificate Program: _____
3. Associate Degree: _____ Degree Program: ________________________
4. Bachelor Degree: _____ Degree Program: ________________________
5. Master Degree/Higher: _____ Degree Program: ________________________
An applicant may document High School Diploma or HSE or College/University degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the
applicable degree being conferred.
Where Does the Applicant Currently Work?
Name of Employer:
Mailing Address of Employer Street City State Zip Code County
Name & Title of Immediate Supervisor:
Your Business Phone: Area Code/Telephone Number Extension Fax # Area Code/Telephone Number
Revised August 2019 BIP Application 7
TRAININGS/EDUCATIONAL HOURS
All applicants must submit proof of the following training/educational contact hours:
1. MCB TIP 25 Self-Study Course
2. 3 hours of live ethics training
3. 50 hours of Batterer Intervention related training topics. The topics should be related to those listed
below but there must be a training certificate showing training regarding topic A – Survivor
safety and sensitivity:
A. Survivor safety and sensitivity
B. The history of the domestic violence movement
C. Cultural diversity
D. The nature and dynamics of domestic violence
E. The difference between batterer intervention and anger management
F. Domestic violence laws and legal issues
G. Responsibility versus denial
H. Sexism and oppression
I. Power and control
J. Facilitation and co-facilitation skills specific to groups
K. Characteristics of men who batter
L. Assessment of intake skills
M. Effects of a batterer’s abuse and violence on children and family
N. Alternate behaviors
All training hours must be documented by transcripts, certificates, in-service logs or other means of
qualifying documentation.
Revised August 2019 BIP Application 8
Applicant’s Agreement to the BIP Ethics Code:
I have read the Current BIP Ethics Code as listed on the MCB web site
www.missouricb.com
, MCB Ethics Code Link and agree to abide by this code:
Print Name Date
Signature Date
AUTHORIZATION AND RELEASE
I hereby certify all of the information given herein is true and complete to the best of my knowledge and
belief. I also authorize any relevant investigations, or the release of personal information to the Missouri
Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. I understand
falsification of any portion of this application/renewal will result in my being denied credentialing, or
revocation of same upon discovery.
I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff,
peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any
action that is within the scope and arise out of the performance of their duties which they, or any of them,
may take in connection with this application/renewal, any examination, the grades with respect to any
examination, and/or the failure of the MCB to issue me said credential or renewal.
This Authorization and Release shall also apply to personal information requested by the Board at any
time following credentialing in connection with any investigation concerning allegations that could lead to
disciplinary action against me.
Print Name Date
Signature Date
Revised August 2019 BIP Application 9
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
FAMILY CARE SAFETY REGISTRY
WORKER REGISTRATION
PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)
CHILD CARE WORKER ($9.00) PERSONAL CARE WORKER ($9.00) xx VOLUNTARY
REGISTRANT
ELDER CARE WORKER ($9.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00) FOSTER PARENT
(NO FEE)
SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NAME
FIRST NAME
MAIDEN AND PRIOR NAMES USED
SOCIAL SECURITY NUMBER
(ATTACH COPY OF SOCIAL
SECURITY CARD)
- -
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
(OPTIONAL)
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
CITY
STATE
ZIP CODE
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
CITY
STATE
ZIP CODE
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME
CONTACT PERSON
ADDRESS
CITY
STATE
SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this
form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to
process this request. Futhermore, I authorized the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care
Safety Registry (FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in 210.921, subsection 1
subdivision (1) and (2), RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective
employer/employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child
care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer
of information to the FCSR within thirty (30) days of receiving the results of the background screening determination.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my
signature below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds
from your account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further
collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)
DATE
/ /
IMPORTANT
• Individuals are required to register one time only.
• Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
• Read back of form for instructions and information on registrant notification and appeal rights
• Send completed registration form, copy of Social Security card and required fee to:
Missouri Department of Health and Senior Services
Attn: Fee Receipts
P.O. Box 570
Jefferson City, MO 65102
MO 580-2421 (FP)
Submit this form with your application and a copy of
your SS card. If your agency has ran a FCSR check
within the last 30 days, you can submit the results
with this form which may speed up the application
process. By doing so, you give permission for your
agency to share their FCSR results.
Revised August 2019 BIP Application 10
Batterer Intervention Professional VERIFICATION FORM
An applicant is applying to the MCB for a Batterer Intervention Professional credential. Please complete this
form and provide a copy to the applicant to include with their application.
Applicant’s Name: ___________________________________________________________________________
Your Name (Print):___________________________________________________________________________
Agency: ___________________________________________________________________________________
Address: ___________________________________________________________________________________
___________________________________________________________________________________________
Telephone: _________________________________________________________________________________
Email: _____________________________________________________________________________________
Today’s Date: _______________________________________________________________________________
Within the last 10 years from the date listed above, please list the composite total number of hours the
applicant spent facilitating or co-facilitating Batterer Intervention Groups:
BIP Group Facilitating Hours: __________
Your Name (Printed): _________________________________________________________________________
Your Signature: ______________________________________________________________________________
Date: ______________________________________________________________________________________
Revised August 2019 BIP Application 11
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
E-mail: help@missouricb.com Jefferson City, MO 65101
BIP PROFESSIONAL REFERENCE FORM
The individual completing this form should be able to provide a professional reference for the
applicant demonstrating that the applicant has developed a working professional relationship with the
below mentioned domestic victim impact service agency. (Please contact the MCB office if you are
having problems getting this form completed)
I. Name of Applicant: _________________________________________________________________
II. Name of Reference (Print):___________________________________________________________
III. Agency of Reference: _______________________________________________________________
IV. Reference Phone Number:____________________________________________________________
V. Reference Address:_________________________________________________________________
VI. Reference Signature___________________________________ Date:________________________
Please describe the nature of your relationship with the applicant and describe why you believe the applicant
is qualified to be a Batterer Intervention Professional:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you ever known the applicant to operate in an unethical manner while performing professional duties
and if so, please describe the behavior?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Criteria For Batterer Intervention Professional (BIP) (Missouri Credentialing Board)

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