First Name Last Name Middle Initial
Date of Birth Location

Please indicate all degrees received and granting institutions

Name of InstitutionDegree received/year


* The following must be submitted or be on file to support your application:
  • Current resume within last 5 years
  • Official transcripts of highest degree held that supports requested privileges
  • Copy of license, certification, or registration

You will have the opportunity to upload the required documentation after completing your application.

Type of License/Certification/RegistrationNumberStateExpiration Date


Date of Hire/Effective Contract Full Time Part Time

Contracted Employee Y N (If Yes, please attach a copy of your current professional liability insurance policy, if applicable)

Health Status

QuestionYesNo
Do you currently have any ongoing physical or mental impairement or condition which would make you unable, with or without reasonable accomodation, to perform all elements of the clnical privileges for which you have applied without a direct threat to the health and safety of others.

NOTE: Physical or mental condition(s) include, but are not limited to, current alcohol or drug dependency, current participation in monitoring programs for alcohol, drug dependency, mental conditions, medical imitation of activity workload, etc., and prescribed medications that may affect your clinical judgment or motor skills.
Within the last two years have you used illegal drugs?
Within the last two years have you or do you:
  • Consume alcohol,
  • Prescribe drugs for yourself;
  • or use chemical substances

to the extent that your ability to competently and safely perform the essential functions of a practitioner in your area of practice is or has been compromised?

Legal Actions/Professional Sanctions



PLEASE SELECT ONE OR MORE CATEGORIES FROM THE DESCRIPTIONS BELOW TO DEFINE YOUR PROFESSIONAL CAPACITY WITH OUR ORGANIZATION. REGARDLESS OF ROLE (REQUIRED)

CASE MANAGER/SUPPORTS COORDINATOR (FORMERLY BACHELOR’S PREPARED SPECIALIST): Individual with a bachelor’s degree in human services but without a license, providing targeted case management, supports coordination, and other services appropriate to the scope of their job. Must be supervised by a QIDP or QMHP.

CHECK HERE IF YOU ARE APPLYING AS A CASE MANAGER/SUPPORT COORDINATOR WITHOUT A LICENSE


CHILD MENTAL HEALTH PROFESSIONAL (CMHP): Individual with specialized training and one year of experience in the examination, evaluation, and treatment of minors and their families and who is a physician, psychologist, licensed or limited-licensed master’s social worker, licensed or limited-licensed professional counselor, or registered nurse; or an individual with at least a bachelor’s degree in a mental health-related field from an accredited school who is trained and has three years supervised experience in the examination, evaluation, and treatment of minors and their families; or an individual with at least a master’s degree in a mental health-related field from an accredited school who is trained and has one year of experience in the examination, evaluation and treatment of minors and their families. For the BHT/ABA services individuals must be a BCBA or BCaBA or Psychologist working within their scope of practice with extensive knowledge and training on behavior analysis and BCBA certified by 9/30/2020. Applicant must provide documentation of a minimum of 24 clock hours annually of formal professional development and training on issues related to assessment and treatment needs of children, no more than 12 hours of which can be obtained through read-and-test internet sites or supervision/case consultation on charts of children.

CHECK HERE IF YOU ARE APPLYING AS AN CMHP


MENTAL HEALTH PARAPROFESSIONAL: An individual that provides specific services that require specialized training, but not a formal education, degree, or license. This may include Parent Support Partners, Crisis Center Line staff, peer supports that have not yet completed their certification, or benefits counselors.

CHECK HERE IF YOU ARE APPLYING AS A MENTAL HEALTH PARAPROFESSIONAL


MENTAL HEALTH PROFESSIONAL:An individual who is trained and experienced in the area of mental illness or developmental disabilities and who is one of the following: a physician, psychologist, registered professional nurse licensed or otherwise authorized to engage in the practice of nursing under part 172 of the public health code (1978 PA 368, MCL 333.17201 to 333.17242), licensed master’s social worker licensed or otherwise authorized to engage in the practice of social work at the master’s level under part 185 of the public health code (1978 PA 368, MCL 333.18501 to 333.18518), licensed professional counselor licensed or otherwise authorized to engage in the practice of counseling under part 181 of the public health code (1978 PA 368, MCL 333.18101 to 333.18177), or a marriage and family therapist licensed or otherwise authorized to engage in the practice of marriage and family therapy under part 169 of the public health code (1978 PA 368, MCL 333.16901 to 333.16915). NOTE: The approved licensures for disciplines identified as a Mental Health Professional include the full, limited and temporary limited categories.

CHECK HERE IF YOU ARE APPLYING AS AN MHP


PARENT SUPPORT PARTNER: Individual who:

CHECK HERE IF YOU ARE APPLYING AS A PARENT SUPPORT PARTNER


PEER SUPPORT SPECIALIST: Individual in a journey of recovery who has a serious mental illness who is now receiving or has received services from the public mental health system. [This is a requirement for any Peer Support Specialist certified after July 1, 2011.] Because of their life experience, they provide expertise that professional disciplines cannot replicate. Individuals employed as Peer Support Specialists serving beneficiaries with mental illness must meet MDHHS specialized training and certification requirements. Peer Support Specialists who assist in the provision of a covered service must be trained and supervised by the qualified provider of that service. Peer Support Specialists who provide covered services without supervision must meet the specific provider qualifications.

CHECK HERE IF YOU ARE APPLYING AS A PEER SUPPORT SPECIALIST


PSYCHOLOGIST: References to "psychologist" in this chart and in the Medicaid Provider Manual mean a psychologist who is fully-licensed, limited-licensed or temporary limited-licensed by the State of Michigan.

CHECK HERE IS YOU ARE APPLYING AS A PSYCHOLOGIST


QUALIFIED BEHAVIORAL HEALTH PROFESSIONAL (QBHP) – QBHP must meet one of the following state requirements:

Extensive knowledge is defined as having taken documented course work at the graduate level at an accredited university in at least three of the six following areas:
  • 1. Ethical considerations.
  • 2. Definitions & characteristics and principles, processes & concepts of behavior.
  • 3. Behavioral assessment and selecting interventions outcomes and strategies.
  • 4. Experimental evaluation of interventions.
  • 5. Measurement of behavior and developing and interpreting behavioral data.
  • 6. Behavioral change procedures and systems supports.
  • CHECK HERE IS YOU ARE APPLYING AS A QBHP


    QUALIFIED MENTAL HEALTH PROFESSIONAL (QMHP): Individual with specialized training or one year experience in treating or working with a person who has mental illness; and is a psychologist, physician, educator with a degree in education from an accredited program, social worker, physical therapist, occupational therapist, speech-language pathologist, audiologist, registered nurse, therapeutic recreation specialist, licensed or limited-licensed professional counselor, or a licensed physician’s assistant. An individual with a bachelor’s degree in a human services field who was hired prior to January 1, 2008 and performed in the role of a QMHP prior to January 1, 2008 would also qualify.

    CHECK HERE IS YOU ARE APPLYING AS A QMHP


    QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP): Individual with specialized training or one year experience in treating or working with a person who has intellectual disability; and is a psychologist, physician, educator with a degree in education from an accredited program, social worker, physical therapist, occupational therapist, speech-language pathologist, audiologist, registered nurse, therapeutic recreation specialist, or a licensed or limited-licensed professional counselor. An individual with a bachelor’s degree in a human services field who was hired prior to January 1, 2008 and performed in the role of a QIDP prior to January 1, 2008 would also qualify.

    CHECK HERE IF YOU ARE APPLYING AS A QIDP


    SOCIAL WORKER: Individual who possesses Michigan full or limited licensure as a master’s social worker or a bachelor’s social worker. Social workers with limited licenses must be supervised by a fully-licensed master's social worker. Student interns pursuing a master’s degree in social work who are a licensed (LBSW) or limited licensed bachelor-level social worker (LLBSW) may perform functions within the scope of practice of the LBSW or LLBSW under the requisite supervision. Student interns pursuing a master’s degree in social work who are not a licensed or limited licensed bachelor-level social worker must be directly supervised through face-to-face contacts with the supervising fully-licensed master’s social worker during assessments and therapy sessions with recipients of services.

    CHECK HERE IF YOU ARE APPLYING AS A SOCIAL WORKER


    SUBSTANCE ABUSE TREATMENT SPECIALIST (SATS): (1) An individual who has licensure in one of the following areas AND is working within their licensure-specified scope of practice: Physician (MD/DO), Licensed Physician's Assistant (PA), Nurse Practitioner (NP), Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Psychologist (LP), Limited-Licensed Psychologist (LLP), Temporary Limited-Licensed Psychologist (TLLP), Licensed Professional Counselor (LPC), Limited-Licensed Professional Counselor (LLPC), Licensed Marriage and Family Therapist (LMFT), Limited-Licensed Marriage and Family Therapist (LLMFT), Licensed Master’s Social Worker (LMSW), Limited-Licensed Master’s Social Worker (LLMSW), Licensed Bachelor’s Social Worker (LBSW), Limited-Licensed Bachelor’s Social Worker (LLBSW) AND they have a registered development plan leading to certification and are timely in its implementation OR are functioning under a time-limited exception plan approved by the Substance Abuse Coordinating Agency (SACA).

    OR

    (2) An individual who has one of the following Michigan Certification Board of Addiction Professionals (MCBAP) or International Certification & Reciprocity Consortium (IC & RC) credentials: Certified Alcohol and Drug Counselor - Michigan (CADC-M), Certified Alcohol and Drug Counselor (CADC), Certified Advanced Alcohol and Drug Counselor (CAADC), Certified Criminal Justice Professional - IC&RC - Reciprocal (CCJP-R), Certified Co-Occurring Disorders Professional – IC&RC (CCDP) – Bachelor's level only, Certified Co-Occurring Disorders Professional Diplomat – IC&RC (CCDP-D) – Master's level only

    OR

    (3) An individual who has one of the following approved alternative certifications: • For medical doctors: American Society of Addiction Medicine (ASAM) • For psychologists: American Psychological Association (APA) specialty in addiction • For counselors/therapists: Certification through the Upper Midwest Indian Council on Addiction Disorders (UMICAD) A physician (MD/DO), physician assistant, nurse practitioner, registered nurse or licensed practical nurse who provides substance use disorder treatment services within their scope of practice is considered to be specifically-focused treatment staff and is not required to obtain MCBAP credentials. If one of these professionals provides substance use disorder treatment services outside their scope of practice, the appropriate MCBAP/IC & RC credential applies. A SATS must be supervised by an individual who is a certified clinical supervisor (a CCS-M or CCS-R) or who has a registered development plan (Development Plan – Supervisor [DP-S]) to obtain the supervisory credential when providing substance abuse treatment services.

    CHECK HERE IF YOU ARE APPLYING AS A SATS


    SUBSTANCE ABUSE TREATMENT PRACTITIONER (SATP): An individual who has a registered MCBAP certification development plan (Development Plan – Counselor [DP-C] – approved development plan in place), is timely in its implementation, and is supervised by a Certified Clinical Supervisor – Michigan (CCS-M) or Certified Clinical Supervisor – IC & RC (CCS); or who has a registered development plan to obtain the supervisory credential (Development Plan – Supervisor [DP-S] - approved development plan in place) while completing the requirements of the plan.

    CHECK HERE IF YOU ARE APPLYING AS AN SATP

    SATP Learning Plan Expiration Date:


    STUDENT INTERN: Individual who:

    • • is a student in one of the following health profession training programs: counseling; marriage and family therapy; psychology; or social work which has been approved by the appropriate board, and
    • • is performing the duties assigned in the course of training, and
    • • is appropriately supervised according to the standards set by the appropriate board and the training program.
    Social work student interns must be pursuing a master’s degree in social work and be supervised by a Licensed Master’s Social Worker in a manner that meets the requirements of a Council on Social Work Education (CSWE) accredited education program curriculum that prepares an individual for licensure.

    CHECK HERE IF YOU ARE APPLYING AS A STUDENT INTERN


    YOUTH PEER SUPPORT SPECIALIST: Individual who:

    • • is a young adult, ages 18 through age 26, with lived experience who received mental health services as a youth, and
    • • is willing and able to self- identify as a person who has or is receiving behavioral health services and is prepared to use that experience in helping others, and
    • • has experience receiving services as a youth in complex, child serving systems preferred (behavioral health, child welfare, juvenile justice, special education, etc.), and
    • • is employed by PIHP/CMHSP or its contract providers, and
    • • is trained in the Michigan Department of Health and Human Services approved curriculum and ongoing training model
    • CHECK HERE IF YOU ARE APPLYING AS A YOUTH PEER SUPPORT SPECIALIST

      Clinical Privileges Requested for Authorization


      CHECK THE FOLLOWING BOX TO PROCEED WITHOUT REQUESTING PRIVILEGES  
      Service Area
       Child/AdolescentAdult
      ActivityFullProvisionalFullProvisional
      Access Management
      Applied Behavior Analysis
      Assertive Community Treatment
      Assessment/Services
          Initial Assessment (Masters Only)
          Psychiatric Evaluation
          Psychological Testing
          Health Care
          Nutrition
      Behavior Treatment Plan Review Committee
      Case Management
      Clubhouse Psychosocial Rehabilitation
      Crisis Counseling (Crisis Center Only)
      * Exempt from Child Training Hours Due to non-billable phone contact only
      Crisis Intervention
      Crisis Stabilization Team
      Dialectical Behavior Therapy Team (DBT)
      Family Training
          Family Psychoeducation
          Parent Support Program
      Home-Based Services (Infant Mental Health)
      Medication Activities
          Medication: Administration
          Medication: Orders
          Medication: Prescribing
          Medication: Evaluation & Management
      Nursing Facility Mental Health Monitoring
      Occupational Therapy
          OT Evaluation/Re-evaluation
          OT Individual & Group
      Peer Support Services
      Substance Abuse Treatment Specialist/Practitioner
      Therapy Services
      Service Planning/Review
      Supported Employment Services
      Supports Intensity Scale (SIS)
      Supports Coordination
      Wraparound Services