Licensed Clinical Social Worker by Completing Provisional

More documents

Recommendations

Info

9. EXPERIENCE: List all employment since the issuance of your provisional license. Begin with today and work back in time. Note any interruptions in time, such as periods of unemployment. Refer to the application instructions for additional direction. From: To: Supervisor: Month/Year Month/Year Organization: Address: Brief Description of Work: From: To: Supervisor: Month/Year Month/Year Organization: Address: Brief Description of Work: From: To: Supervisor: Month/Year Month/Year Organization: Address: Brief Description of Work: From: To: Supervisor: Month/Year Month/Year Organization: Address: Brief Description of Work: Revised 8/2013 Page 2 of 3
HISTORY 10. Have you ever, or are you now, providing any of the services regulated by W.S. 33-38-101 et seq. in the State of Wyoming, without meeting the requirement for licensure or certification, or without meeting an exemption provided in W.S. 33-38-103? Yes No 11. Has any state rejected or denied your application for certification or licensure in any profession? Yes No 12. Has any state revoked, suspended, refused to renew, or otherwise restricted your certificate or license in any profession? 13. Have you ever voluntarily surrendered your certificate or license in any profession in order to avoid disciplinary action by a regulatory agency in any state? Yes Yes No No 14. Have you ever been sanctioned by a professional association? Yes No 15. Have you been convicted of a misdemeanor involving moral turpitude, including pleas of nolo contendere or no contest? Yes No 16. Have you been convicted of a felony in any profession, including pleas of nolo contendere or no contest? Yes No 17. Are you addicted to, or do you habitually use alcohol, any controlled substance, or other drugs having similar effects? Yes No 18. Have you ever been judged incompetent by a court of law? Yes No 19. Have you ever violated and been convicted of a charge under the Wyoming Controlled Substances Act? Yes No Attach a written explanation if you answered "YES" to any of questions 10 through 19 above. Include documentation related to your “YES” answer(s), including, but not limited to, certified copies of court records, letters of sanction, state board disciplinary action documents, etc. WARNING Making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.) AGREEMENT In signing this application, I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated by the Mental Health Professions Licensing Board, and W.S. § 33-38-101 through 113. I also agree to adhere to the codes of ethics applicable to my profession and this application. AFFIDAVIT The undersigned, being duly sworn, deposes and says that he or she is the person making the foregoing statements and that they are made in good faith and are true in every respect. SIGNATURE OF APPLICANT DATE Revised 8/2013 Page 3 of 3
Page 1 and 2: APPLICATION INSTRUCTIONS Licensed C
Page 3: MENTAL HEALTH PROFESSIONS LICENSING
Page 7 and 8: CLINICAL EXPERIENCE Report the amou

Licensed Clinical Social Worker by Completing Provisional

Create successful ePaper yourself

Delete template?

Save as template?