ࡱ> %  CE G I K M OQSU%` wbjbjٕ #[O%6 6 6 $Z r\Z # LdY$="h$v6 #)^6   h6  > Bj ^d 0#  %%,%6 x @MR{i t^ # Z Z Z j>vdFZ Z Z >vZ Z Z   Application for Certified Associate Sex Offender TherapistCOMPLETE ALL PARTS OF THIS FORM. PLEASE TYPE OR PRINT IN BLACK OR BLUE INK. Call the Health Licensing Agency if you have any questions. Incomplete applications will be returned. Use N/A to indicate information that is not applicable. This information will be used by OHLA staff to conduct a criminal history check, a background investigation, and to document your qualifications. 1. Applicant InformationAPPLICANTS NAME LAST FIRST MIDDLE INTIAL  FORMTEXT        FORMTEXT        FORMTEXT  MAILING ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      COUNTY  FORMTEXT      TELEPHONE (  FORMTEXT     )  FORMTEXT       FORMTEXT      SOCIAL SECURITY NUMBER (REQUIRED)  FORMTEXT       FORMTEXT      FORMTEXT    GENDER  FORMCHECKBOX  Female  FORMCHECKBOX  MaleBIRTHDATE (MO/DAY/YR)  FORMTEXT    /  FORMTEXT    /  FORMTEXT     PLACE OF BIRTH (CITY / STATE)  FORMTEXT        Have you ever been known under any other name?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If yes, list full name(s):  FORMTEXT      2. Oregon State Licensure / Certification / Registration InformationPROFESSIONISSUE DATELICENSE/CERTIFICATION/REGISTRATION NO. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3. Previous Licensure or CertificationList all states where certification(s), license(s), or registrations were held. List certification(s), license(s), or registrations approved as temporary, license by license (reciprocity, exclusion or comparable with type, date, grantor, and if certification(s), license(s), or registration is current. STATE / JURISDICTIONPROFESSIONCERTIFICATE OR LICENSEPERMANENT OR TEMPORARY  LICENSE RECEIVED BY LICENSE REVCEIVED BYCURRENTLY IN FORCEYR ISSUEDNUMBEREXAMOTHER FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  YES  FORMCHECKBOX  NO FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  YES  FORMCHECKBOX  NO4. EducationFULL NAME, CITY AND STATE SCHOOLS ATTTENDED ATTENDANCE DATE GRADUATED DEGREE EARNED MAJOR AREA OF STUDY IF NO DEGREE, # OF SEMESTER/QTR HOURS EARNEDENTRANCE DATEENDING DATE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      5. Individual records questions YES NO 1. Have you ever been convicted, entered a plea of guilty, nolo contendere or a plea of similar effect, or had prosecution or sentence deferred or suspended, in connection with: a. the use or distribution of controlled substances or legend drugs?  FORMCHECKBOX   FORMCHECKBOX  b. a charge of a sex offense?  FORMCHECKBOX   FORMCHECKBOX  c. any other crime, other than minor traffic infractions? (Including driving under the influence and reckless driving)  FORMCHECKBOX   FORMCHECKBOX  2. Have you ever been found in any civil, administrative or criminal proceedings to have: a. possessed, used, prescribed for use, or distributed controlled substances or legend drugs in any way other than or legitimate or therapeutic purposes, diverted controlled substances or legend drugs, violated any drug law, or prescribed controlled substances for yourself?  FORMCHECKBOX   FORMCHECKBOX  b. committed any act involving moral turpitude, dishonesty or corruption?  FORMCHECKBOX   FORMCHECKBOX  c. violated any state or federal law or rule regulating the practice of a health care professional?  FORMCHECKBOX   FORMCHECKBOX  3. Are you aware of any current, proposed, impending or threatened civil or criminal action against you? This includes whether or not a claim, charge or filing was actually made with a court.  FORMCHECKBOX   FORMCHECKBOX  4. Do you currently, or have you had within the past 5 years, any physical, mental, or emotional condition which impaired, or does impair your ability to practice your profession safely and competently?  FORMCHECKBOX   FORMCHECKBOX  5. Do you currently have, or have you had within the past 5 years, a dependency on the use of alcohol or drugs which impaired, or does impair, your ability to practice your health care profession safely and competently?  FORMCHECKBOX   FORMCHECKBOX  6. Within the past five years, have you entered into a diversion program for evaluation, treatment or monitoring for substance abuse or dependency, or for correction of communication or boundary issues, in lieu of or as a condition of resolving a matter before a health care program or facility, regulatory or licensing Board, or criminal or civil court; or have you been notified that such action is pending or proposed?  FORMCHECKBOX   FORMCHECKBOX  6. Professional ExperienceList all professional work experience, listing the most recent first. (Attach additional pages as needed) DATES# OF HOURS PER WEEK NAME AND ADDRESS OF INSTITUTION PLACE OF PRACTICE OR OTHERDEGREE/CERTIFICATE AND DATE RECEIVED NATURE OF EXPERIENCE OR SPECIALTYFROM (MO/YR)TO (MO/YR) FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT      ORS 675.375(4) Professional Experience Requirement for Applicants. To qualify as a certified associate sex offender therapist, the applicant must be in compliance with applicable provisions and rules adopted by the agency. The applicant must have a least a bachelors degree in the behavioral sciences and have had a minimum of 1000 hours of direct clinical contact with sex offenders. In addition the applicant must have 30 hours of formal training applicable to sex offender treatment and evaluation, achieved within the three years prior to this application. The applicant must also be under direct supervision of a certified clinical sex offender therapist. Do you have a Bachelors degree or higher in behavioral sciences?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have a total of 1000 hours of direct treatment experience?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have 30 hours of formal training applicable to sex offender treatment and evaluation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No7. Supervisors InformationPlease provide name, address and telephone number of your supervisor which you will be using when working with clients: Provide a copy of the contract entered into by yourself and supervisor ORS 675.375(4). Supervisor s Name FORMTEXT       Work Telephone FORMTEXT       Home Telephone FORMTEXT       Supervisor s Address FORMTEXT       City FORMTEXT       State FORMTEXT       Zip FORMTEXT       8. Social Security NumberAs part of your application for initial or renewed occupational, professional or recreational license, certification, or registration issued by the Health Licensing Agency, you are required to provide your Social Security Number to the Health Licensing Agency. This is mandatory. The authority for this requirement is ORS 25.785, ORS 305.385, 42 USC 405(c)(2)(C)(i), and 42 USC 666(a)(13). Failure to provide your Social Security Number will be a basis to refuse to issue or renew the license, certification, or registration you seek. This record of your Social Security Number is used for child support enforcement and tax administration purposes (including identification) only, unless you authorize other uses of the number. Although a number other than your Social Security Number appears on the face of the licenses, certificates, or registrations issued by the Health Licensing Agency, your Social Security Number will remain on file with the Health Licensing Agency. 9. Applicants Attestation I,  FORMTEXT       , certify that I am the person described and identified in this application; NAME OF APPLICANT I have read ORS 675.375 and OAR 331-820-0010; I have answered all questions truthfully and completely, and the documentation provided in support of my application is, to the best of my knowledge, accurate. I further understand that the Oregon Health Licensing Agency may require additional information from me prior to making a determination regarding my application, and may independently validate conviction records with official state or federal databases. I hereby authorize all hospitals, institutions or organizations, my references, employers (past and present), business and professional associates (past and present), and all governmental agencies and instrumentalities (local, state, federal, or foreign) to release to the OHLA any information, files or records required by OHLA in connection with processing this application. I further affirm that I will keep the OHLA informed of any criminal charges and/or physical or mental conditions which jeopardize the quality of care rendered by me to the public. Should I furnish any false or misleading information on this application, I hereby understand that such act shall constitute cause for the denial, suspension, or revocation of my license to practice in the State of Oregon. Signature of Applicant: Date:  FORMTEXT          Application Checklist  (The following items need to be submitted before completing application)  FORMCHECKBOX  OFFICIAL TRANSCRIPTS Official Transcripts must be submitted directly to the Oregon Health Licensing Agency from an accredited College or University verifying the degree in behavioral sciences. Official Transcripts must be received and filed with the Oregon Health Licensing Agency before completing this application.  FORMCHECKBOX  Supervision contract (The following items need to be submitted with application)  FORMCHECKBOX  Verification for completion of supervised experience form  FORMCHECKBOX  Formal training qualifications form  FORMCHECKBOX  A copy of one of the following: drivers license, state ID card, passport or military ID card.  FORMCHECKBOX  Application and certification fees  FORMCHECKBOX  Application is completed, signed, and dated. Associate  Formal Training Supervision Contract Completion of Supervised Experience Finger Print Card Formal Training Qualifications List 30 hours of formal training received within the last three years preceding the date of this application. Training must be directly related to the treatment and evaluation of sex offenders or victims of abuse in the following essential subjects: Completion of formal training shall include documenting 75%, or 22 hours of the total required hours, in the following essential subjects: (A) Assessment and diagnosis; (B) Cognitive therapy; (C) Counseling and psychotherapy; (D) Cultural/ethnic issues; (E) Ethics applicable to working with a forensic population; (F) Human development with special attention to sexual development and healthy sexuality; (G) Interviewing skills; (H) Knowledge of family dynamics as related to sex offending; (I) Psychometric and psycho-physiological testing; (J) Psychopathology; (K) Relapse prevention; (L) Relationship and social skills training; (M) Risk assessment; (N) Sexual arousal control; (O) Social support networks; (P) Victim awareness and empathy. Completion of formal training shall include documenting 25%, or 8 hours of the total required hours, in the following areas of training and knowledge: (A) Supervision; (B) Assessment and treatment of mental illness including neuropsychological disorders; (C) Couples and family therapy; (D) Family reunification; (E) Pharmacological therapy; (F) Substance abuse treatment. Refer to ORS 675.375(3) and OAR 331-810-0010(5)(a). Use additional pages as needed to document required training. EVENT  DATE LOCATION SPONSOR HOURS FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Certified Associate Sex Offender Therapist Supervision Contract 1. Associate s InformationNAME LAST FIRST MIDDLE INTIAL  FORMTEXT        FORMTEXT        FORMTEXT  BIRTHDATE (MONTH/DAY/YEAR)  FORMTEXT       /  FORMTEXT    /  FORMTEXT     UNDERLYING CREDENTIAL NUMBER  FORMTEXT      STREET ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      2. Supervisor InformationNAME LAST FIRST MIDDLE INTIAL  FORMTEXT        FORMTEXT        FORMTEXT      SOTB CREDENTIAL NUMBER  FORMTEXT      UNDERLYING CREDENTIAL NUMBER  FORMTEXT      STREET ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT       ORS 675.375(4) Supervision of Associate s. Supervision of associate s requires that the provider take full ethical and legal responsibility for the quality of work of the associate. Supervision of associates shall involve regular, direct, face-to-face supervision. This supervision contract must be submitted to the agency for approval and shall include (please attach documentation addressing these items): Supervised areas of professional activity. Amount of supervision time and the frequency of supervisory meetings. This information may be presented as a ratio of supervisory time to clinical work conducted by the associate. Supervisory fees and business arrangements. Nature of the supervisory relationship and the anticipated process of supervision. Selection and review of clinical cases. Methodology for recordkeeping, evaluation of the associate, and feedback. How the associate will be represented to the public and the parties. Provider: Avoid presenting as having qualifications in areas that he or she does not have them. Provide sufficient training and supervision to the associate to assure the health and safety of the client and community. Have expertise and knowledge to directly supervise the associates work. Assure the associate being supervised has sufficient and appropriate education, background, and preparation for the work he or she will be doing. Cosign all written reports and correspondence prepared by the associate. Do not undertake a contract that exceeds the providers ability to comply with the supervision standards. Assure that the associate is prepared to conduct professional work, and must assure adequate supervision of the associate. The provider shall meet face-to-face with the associate a minimum of two hours for every 45 hours of supervised professional work. Supervision meetings shall regularly occur at least every other week. Supervise no more than two associates. All work conducted by the associate is the responsibility of the provider. The provider shall have authority to direct the practice of the associate. It is the providers responsibility to correct problems or end the supervision contract if the associates work does not protect the interests of the clients and community. If the provider ends the contract, he or she must notify the agency in writing within thirty days of ending the contract. A provider may only change or adjust a supervision contract after receiving written approval from the agency. Supervision is a power relationship. The provider must not use his or her position to take advantage of the associate. The provider shall ensure that the associate has completed at least one thousand hours of supervised evaluation and treatment experience before the associate is authorized to evaluate and treat sex offenders. The provider will submit to the agency documentation that the associate has completed a minimum of one thousand hours within thirty days of completion of the experience. Associate: Represent him or herself as an associate only when performing clinical work supervised by the contracted provider. 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I certify that the information included in this contract is accurate, and that I have read and understand the requirements in ORS 675.375(4) Supervision of associate s.  FORMTEXT        FORMTEXT       Print supervisor name Print associate applicant name Supervisor signature Associate applicant signature  FORMTEXT        FORMTEXT       Date Date Certified Associate Sex Offender Therapist Verification for Completion of Supervised Experience 1. ApplicantUse a separate form for each supervisor verifying your evaluation and treatment experience for each practice setting. This form may be duplicated. Fill out Section 1 and forward the verification form to your super