Member Contract

Member Contract

Clinician  _____  Name ___________________________________

Counselor  _____  Address __________________________________

Allied Professional _____    ___________________________________

Email __________________  Phone ___________________________________

(Clinicians include Licensed Psychiatrists, Psychologists, Behavioral Specialty Nurse Practitioners or Nurse Specialists, Clinical Social Workers, Professional Counselors or Marriage & Family Therapists regulated by the Colorado Department of Regulatory Agencies (DORA) and Nationally Certified Pastoral Counselors. Counselors include matriculating graduate or doctoral behavioral health field students and/or interns, addictions counselors, and/or candidates for licensure or certification in a behavioral health field who are registered with DORA as unlicensed psychotherapists. Allied professionals include health professionals regulated by DORA who practice whole-person, behaviorally oriented care giving or ecclesially affiliated, ordained ministers with Master of Divinity or Clinical Pastoral Education training. )

Academic Credentials (Degrees, Certificates) please provide copies

and Current Academic Matriculation/Enrollments:

Institution_______________________ Degree/Cert________  Year Completed

_______________________________ __________________ _____________

_______________________________ __________________ _____________

_______________________________ __________________ _____________

_______________________________ __________________ _____________

Clinical Credentials (Licensure, Certifications) please provide copies:

Discipline_______________________ License/Cert Number_ Initial Date____

_______________________________ __________________ _____________

_______________________________ __________________ _____________

_______________________________ __________________ _____________

_______________________________ __________________ _____________

Professional Association Memberships:

Organization Name________________ Membership Number_ Years Active__

________________________________ __________________ ____________

________________________________ __________________ ____________

________________________________ __________________ ____________

Professional Liability Coverage please attach policy cover sheet copy:

Provider (Company Name)_________ Policy Number______ Effective Date

_______________________________ __________________ ____________

Access & Availability:

Days, Hours of Operation: __________________________________________________

Site (check one or both): Consortium Office ____; Alternate Address ____ (list below)

Alternate Office / Counseling Site: ___________________________________________

Maximum Acceptable Clinical Contacts per Month: _____________________________

Maximum Acceptable Number of Active Consortium Clients: _____________________

Agreements

I agree to abide by the ethical standards of one or more of the following professional organizations: American Psychiatric Association; American Psychological Association; American Nursing Association; National Association of Social Workers; American Counseling Association; American Association of Marriage & Family Therapists; National Association of Drug & Alcohol Counselors; American Association of Pastoral Counselors (submit an alternate association guideline for approval if desired). Please attach a signed copy of those guidelines with this application.

I agree to fully respect the validity and dignity of any client/consumer of CCC services, particularly gay, lesbian, bisexual, transgender, adjudicated, undocumented, criminally convicted, sex offense registered, nonviolent, civilly disobedient or any other potentially discounted person due to their sexual, social or political orientation. I also agree to routinely consult with or receive clinical supervision with members to review potential counter transference, burnout or discrimination. Clinicans or Allied Professionals should acquire a minimum of 1/4-hr consultation monthly; Counselors 1 hour monthly supervison. Consortium members will be listed in a published roster for public use to receive referrals for services.

I agree to collect the customary $5.00 fee per clinical contact with medically indigent CCC clients as full payment for the services received, and to waive or accept supplemental stipends as the CCC budget allows according to available funding. In addition, I agree to receive fees in exchange for the same level of care I provide to consumers with 3rd party reimbursements or full private pay fees, in support of the CCC’s philosophy that the voluntary, dignified utilization of behavioral healthcare is an integral part of effective services, and, that CCC clients are thus aided in becoming more effective consumers of behavioral healthcare (and comprehensive healthcare in general.)

__________________________________________   ____________

CCC Member Applicant signature      date