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Massachusetts TA Gambling Certification2

This is the form for the Gambling TA Center application.

"*" indicates required fields

Step 1 of 7 - Personal Information

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Name*
Address*
Work Address*
Are you currently licensed or certified?*
What type of certificate are you applying for
Check the appropriate box below for education and experience level
Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
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      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?*
      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?*
      Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
      Are you an independent practitioner in a private practice?*
      Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
      I agree to these ethical codes below:*
      1. I will support all personal and professional efforts toward a primary goal of recovery for myself, the client and his/her family.
      2. I will be and remain committed to the highest quality therapeutic care for those who seek my professional services.
      3. I will contribute myself and my work to the best interest of my client and his/her needs.
      4. 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.
      5. 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.
      6. I will adhere to all policies and management functions within my institution, and advance said policies and functions with my clients.
      7. 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.
      8. I will manage my own conduct in all areas, including abuse or misuse of gambling, alcohol and other drugs and other addictive behaviors.
      9. I will only state any personal capabilities or professional qualifications actually gained.
      10. I will not impose my own view on gambling or any issues related to gambling on my clients.
      Disciplinary History
      Has any disciplinary action been taken against you by a licensing/certification board located in the United States or any country or foreign jurisdiction?*
      Are you the subject of pending disciplinary action by a licensing/certification board located in the United States or any country or foreign jurisdiction?*
      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?*
      Have you ever been denied a professional license in the United States or any country or foreign jurisdiction?*
      CONSENT TO RELEASE OF INFORMATION*
      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?*
      • 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*
      Practice Address*
      I currently maintain professional liability insurance
      Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
      Do you also treat family members of the problem gambler?
      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.
      MM slash DD slash YYYY
      On the next page you will submit your payment information with PayPal.
      This field is for validation purposes and should be left unchanged.
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