2018/02/07 Council Agenda Packet

AGENCY PERSONNEL INFORMATION AND MATERIALS .` Administrator providing management or supervision of services Name Title Include with this application the following materials regarding the person named as administrator: ❑ Evidence that the administrator is appointed by the governing body, as required by WAC 388-877-0400(1)(a copy of a letter of appointment signed by a member of the governing body or a governing body signature on the administrator's job description). ❑ A copy of the job description signed and dated by the appointed administrator that includes the new administrator's commitment to performing the key responsibilities listed in WAC 388-877-0400. O A copy of the report of findings from a Washington State Patrol criminal background check conducted within the last year. O A copy of the report of findings of a criminal background check from the last state of residence if the person has lived out-of-state within the past three years. Mental Health Clinical Supervisor Name (as listed on the current credential) Title Substance Use Disorder Clinical Supervisor ""` Name (as listed on the current credential) Title Problem and Pathological Gambling Clinical Supervisor Name (as listed on the current credential) Title Include the following materials regarding the person named as clinical supervisor: ❑ A copy of the job description signed and dated by the clinical supervisor and his or her supervisor. ❑ A copy of the result of a criminal background check that has been completed by the Washington State Patrol within the last 365 days on the person appointed. For Mental Health: ❑ Documentation of 15 hours of training in clinical supervision approved by the Department of Health, ❑ For Agency Affiliated Registrations,please also include a copy of MHP recognition and/or a copy of Master's Degree and resume. For Substance Use Disorder: ❑ Documentation of competency in clinical supervision (college course or certificate of training in clinical supervision). ❑ A copy of the report of findings of a criminal background check from the last state of residence if the person has lived out-of-state within the past three years For Problem and Pathological Gambling: ❑ Documentation of a valid international gambling counselor certification board-approved clinical consultant credential,a valid Washington state certified gambling counselor II certification credential,or a valid national certified gambling counselor II certification credential;and ❑ Documentation of training on gambling-specific clinical supervision approved by a state, national,or international organization. Additional Personnel Requirements for Substance Use Disorder Agencies Alcohol/Drug Information School (ADIS) Instructor(if applying for ADIS certification) Name Title When applicable,submit the following materials regarding the person named as ADIS Instructor with this form: ❑ A copy of the job description signed and dated by the person named and the person's supervisor. ❑ If the ADIS Instructor is not a CDP,a copy of an Alcohol/Drug Information School Instructor Certificate issued by a community college approved by the Washington State Division of Behavioral Health and Recovery. Agency Accreditation Information Is your agency accredited? ❑ Yes ❑ No If yes,check the organization that accredits your agency: ❑ Commission on Accreditation of Rehabilitation Facilities(CARF) ❑ Council on Accreditation(COA) ❑ The Joint Commission ❑ Washington State Division of Behavioral Health and Recovery(DBHR). (Opiate Treatment Programs only.) Do you want your accreditation listed in the Directory? ❑ Yes. (If yes,attach a copy of your current accreditation certificate.) ❑ No Do you want to be contacted about becoming a"deemed agency" under WAC 388-877-0310? ❑ Yes ❑ No Revised 10/5/17 Page 7 of 8