Application for Recertification As a Certified Preadmission Screening Clinician______

Application for Recertification as a Certified Preadmission Screening Clinician______

This is a fillable form. Please use the sections marked “Click here to enter text” to answer questions. Once signed, scan into PDF and email the completed application to .

Name of Applicant: Click here to enter text.

If this is a different name than the one the applicant is currently certified under please indicate previous name here: Click here to enter text.

Name of Community Services Board: Click here to enter text.

Expiration date of current certification: Click here to enter a date.

Since last certification have you become licensed? Yes ☐ No ☐

Since last certification have you enrolled for supervision for licensure? Yes ☐ No ☐

If the individual is certified under the requirements for retaining experienced staff [grandfathering], please indicate here that this is a request for a one year certification: Choose an item.

Submission of this form is an attestation by applicant and sponsoring Community Services Board that applicant has met the ongoing requirements for clinical supervision, continuing education and continuing to conduct preadmission screenings. Please check off to affirm this. ☐

Applicant or is a qualified supervisor orhas received a minimum of 12 hours of clinical supervision from a qualified supervisor: Yes ☐ No ☐

Applicant has completed a minimum of 16 hours of relevant continuing education: Yes ☐ No☐

Applicant has conducted preadmission screening evaluations during the last certification period:

Yes ☐ No ☐

If applicant has not met these requirements due to extenuating circumstances, they must request a variance before applying for recertification. If the CSB provides DBHDS with a Request for Variance demonstrating the need, based on hardship, to retain an individual who neither meets the new minimum educational standards nor fits the retention criteria above, DBHDS will make a decision as to whether to certify that person under these provisions. The CSB will be required to develop a plan to address the situation that has created the hardship and will develop a plan of action to come into compliance.

Signature of Applicant:______Date:______

The following signatures attest that this individual has met all requirements for recertification and is competent to be recertified.

Signature of Supervisor:______Date:______

Signature of Emergency Services Manager:______Date:______

Approval of submission for recertification:

Signature of Executive Director:______Date:______

Virginia Department of Behavioral Health & Developmental Services

Updated January 2017