Massachusetts TA Gambling Certification2 This is the form for the Gambling TA Center application. "*" indicates required fields Step 1 of 7 - Personal Information 14% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone number*Email Current Employer* Job Title* Work Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently licensed or certified?* Yes No License #* What type of certificate are you applying for First time registration Registration renewal Lapsed registration renewal Check the appropriate box below for education and experience level Master’s or doctoral degree with 1 year of addiction-related clinically supervised experience Bachelor’s degree with 2 years of addiction-related clinically supervised experience High School diploma with an internship and 3 years of addiction-related clinically supervised experience. Name of institution and degree earned* Please briefly describe addiction-related clinical experience. (100 word count)*Upload (PDF) your resume demonstrating clinical experience and include references for each applicable experience.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.HiddenUpload (PDF) of 30 CEUs hours of gambling specific training that may include face-to-face or online trainings. Submitted CEUs will be reviewed by HRiA.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.Upload (PDF) of 30 CEUs hours of gambling specific training that may include face-to-face or online trainings. Submitted CEUs will be reviewed by HRiA.* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Upload (PDF) of 15 CEUs hours of gambling specific training that may include face-to-face or online trainings. Submitted CEUs will be reviewed by HRiA.* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. On-going documented supervision regarding gambling specific or addiction disorder cases with a supervisor is necessary for initial certification. This requirement is not necessary if you currently work as a clinical supervisor or are a licensed, independent practitioner in private practice. Please select one statement below:Do you receive regular clinical supervision regarding gambling specific or addiction disorder cases?* Yes No If yes, please upload a letter from your supervisor stating that you receive regular clinical supervision and that problem gambling issues will be discussed as they arise with clients.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.The letter must: A description of the applicant’s direct contact with supervision regarding gambling disorder and/or addiction cases. (Group or individual supervision is allowed, but time spent in staff meetings or administrative meetings is not.) A description of the supervised work position and work setting/program during the clinical supervision. The supervisor’s signature and/or sign-off on the supervision. The supervisor’s professional qualifications Are you a clinical supervisor?* Yes No please upload a letter from your place of employment certifying your position*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.Are you an independent practitioner in a private practice?* Yes No please upload a copy of your independent license showing you are in good standing.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB. I agree to these ethical codes below:* I agree to the code of conduct listed below I will support all personal and professional efforts toward a primary goal of recovery for myself, the client and his/her family. I will be and remain committed to the highest quality therapeutic care for those who seek my professional services. I will contribute myself and my work to the best interest of my client and his/her needs. I will preserve an objective, professional relationship with the client at all times and use my clinical supervision resources if this relationship falls out of balance. I will follow the laws and regulations pertaining to the confidentiality of all records, material and knowledge concerning the client and equal service to all clients. I will adhere to all policies and management functions within my institution, and advance said policies and functions with my clients. I will continue to assess my own personal strengths, limitations, biases and effectiveness regularly and understand my responsibility for professional growth through further education and training. I will manage my own conduct in all areas, including abuse or misuse of gambling, alcohol and other drugs and other addictive behaviors. I will only state any personal capabilities or professional qualifications actually gained. I will not impose my own view on gambling or any issues related to gambling on my clients. Disciplinary HistoryHas any disciplinary action been taken against you by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Are you the subject of pending disciplinary action by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Have you voluntarily surrendered or resigned a professional license (does not include non- renewal or expired licenses) to a licensing/certification board in the United States or any country or foreign jurisdiction?* Yes No Have you ever been denied a professional license in the United States or any country or foreign jurisdiction?* Yes No Please explain why you answered "yes" to any of the above questions:* CONSENT TO RELEASE OF INFORMATION* I consent to the information release below By checking the box above and providing your digital signature, you are consenting to the following: I give permission to HRiA to request information from my present and past employers, and any institution or agency with which I am or have been associated. Information may be obtained from any individual (from my associations shared in this document), to determine my professional competence and accomplishments. I consent to HRiA inspecting any documents or records necessary to determine my “acceptable standard” to receive the MA PGS certificate. I hereby release from any liability all representatives of HRiA and all individuals and organizations who provide information to HRiA while acting in good faith, to determine my credentials. I am aware that any false or misleading information deliberately given will be considered a serious matter, and will be dealt with accordingly. I understand that this release expires one year from the signature date. Would you like to receive treatment referrals for your agency from HRiA?* Yes No Please provide the following information* Contact information (name of agency, address, phone number) Fees Insurance coverage Other important referral information Would you like to receive treatment referrals for private practice from HRiA* Yes No Practice Name* Credentials* Practice Name* Practice Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Practice Email Practice Website Please list payment options: (i.e. insurance taken, sliding scale, set fee, etc.) Days/hours of the week open:I currently maintain professional liability insurance Yes No through the following insurer: submit a copy of liability insuranceAccepted file types: pdf, doc, docx, Max. file size: 10 MB.Do you also treat family members of the problem gambler? Yes No Any other specialties? If so please list Digital Signature*By signing your name in the box below, it is the same as a wet signature on a legal document. I certify that all answers above are truthful to the best of my knowledge. Date MM slash DD slash YYYY On the next page you will submit your payment information with PayPal. CommentsThis field is for validation purposes and should be left unchanged.