Community Behavioral Health Services - San Francisco Department ...

Hjfh;aksjd City and County of San Francisco Compliance/Provider Relations UnitDepartment of Public Health1380 Howard St., 2 nd FloorCOMMUNITY PROGRAMS San Francisco, CA 94103Attestation for Non-Licensed StaffTo be completed and signed by Supervisor and faxed to: Avatar Accounts Manager at 415-252-3008Staff Name: ________________________________________________________________________ Program Name:__________________________________ RU: _____________________Street Address:___________________________ City: _____________________ State: ______ Zip Code: ___________Agency Phone: _____________ Agency Fax: ____________Supervisor Name: ____________________________Title: _______________________________Graduate Student Trainee (individual participating in a field intern/trainee placement while enrolled in an accredited Masters inSocial Work (MSW) or Masters of Art (MA)/Masters of Science (MS) Counseling training program.I attest that _____________________ (student) is a Graduate Student Trainee from ____________________, anaccredited higher education institution, who began interning at our agency on _____/______/_______ (date).Mental Health Rehabilitation Specialist (MHRS)that _____________________ (staff) meets the requirements for an MHRS because of one of the following situations.Master’s Degree in a mentalhealth related field and two (2) years experience in a mental health setting. OR Bachelor’s Degree in a mental healthI attestrelated field & four (4) years experience in a mental health setting. OR Associate Arts Degree in a mental health relatedfield and six (6) years experience in a mental health setting.Mental Health Advocate and Other Staff not included in above categoriesI attest that _____________________ (staff) has graduated from High School or possess a GED. This staff person willbe under my supervision and I will be responsible for oversight of their work at the agency.Substance Abuse Counselors who are not licensed, certified, or registeredI attest that _____________________ (staff/student trainee) has begun employment/training/internship at the agency on_____/______/______(start date) and that the staff/student trainee will become registered with a recognized certifyingagency* within six (6) months of their start date.Supervisor Signature: ________________________ Title: _______________________ Date:__________*Includes the following:American Academy of Health Care Providers in the AddictiveDisordersAssociation of Christian Alcohol & Drug CounselorsBoard for Certification of Addiction SpecialistsBreining InstituteCalifornia Association for Alcohol and Drug EducatorsCalifornia Association of Drinking Driver Treatment ProgramsCalifornia Certification Board of Alcohol and Drug CounselorsCalifornia Certification Board of Chemical DependencyCounselorsCenter for Criminality Addictions Research, Training, andApplicationIndian Alcoholism Commission of California, Inc.4