| VCE Annual Report 2007-08 Register | Sign In
Site search
Virtual Center of Excellence design: square-header Member Registration design: arrow-white Calendar   
Home » Member Registration

M E M B E R S H I P     F O R M
* Indicates Required Field!
Blue Indicates For Your Information!
Personal Information
First Name*   Last Name*
Best phone number to reach you*   Ethnicity
Gender   Year you were born *
Home Zip Code*
UserID/Email *   Must be a valid email address. Learn how to get your own email
Confirm UserID/Email*
Password *   should be more than 6 characters and should not contain<,>,',",(,)
Confirm Password *  

Employment Information
Your County * 
Primary Job
Organization *
Organization Address *
Secondary Job
Organization
Organization Address

Certificates & Certifications (Check all that apply)
Addictions Counselors
 Certified Addictions Counselor - Reciprocal (CAC-R)
 Certified Clinical Specialist (MCBAP)
 Certified Criminal Justice Specialist Professional (CCJP)
 Certified Prevention Specialist - Reciprocal (CPS-R)
Infant Mental Health Specialists
 Infant Family Associate
 Infant Family Specialist
 Infant Mental Health Graduate Certificate
 Infant Mental Health Mentor
 Infant Mental Health Specialist
 Infant Mental Health Therapist
Miscellaneous
 Family Psycho-Education
 Parent Management Training-Oregon (PMTO)
 Peer Support Specialists
 Sex Therapist
Nursing Assistant
 Certified Home Health Aide
 Certified Nursing Assistant (CNA)
 Certified Occupational Therapist Assistant (COTA)
 Certified Recreational Therapist
 Nursing Assistant-Registered (NA/R)
 State Tested Nurse Aide (STNA)
Supervision
 Direct Care Supervision Certificate (MSU)
 Retention-Focused Supervision Certificate (MSU)
Training Program Certificate
 Child and adolescent functional assessment scale (CAFAS)
 Foster Care (VCE)
 Retention-Focused Supervision Certificate (MSU/VCE)
 Wraparound
Service Type * (You must check at least one)
 Administration
 Assertive Community Treatment (ACT)
 Child Mental Health Professional (CMHP)
 Community Mental Health/Juvenile Justice/Wraparound (CMH/JJ/WRAP)
 Family PsychoEducation (FPE)
 Infant Mental Health (IMH)
 Integrated Dual Diagnosis Treatment (IDDT)
 Parent Management Training-Oregon (PMTO)
 Peer Support Specialist
 Qualified Mental Health Professional
 Qualified Mental Retardation Professional (QMRP)
 Substance Abuse Treatment Practitioner
 Substance Abuse Treatment Specialist
 Supported Employment
 Other
Other Certificates & Certifications

Other Information
Job Category *
Highest Degree Earned *
 
License Category (Check all that apply) License number
(enter alpha-numeric)
Counseling
  Licensed Professional Counselor (LPC)
Limited Licensed Professional Counselor (LLPC)
 
Marriage & Family Therapy
  Licensed Marriage & Family Therapist (LMFT)
Limited Licensed Marriage & Family Therapist (LLMFT)
 
Nursing
  Certified Nurse Aide (CNA)
Licensed Practical Nurse (LPN)
Registered Nurse (RN)

 
Physician
  Controlled substance
DEA registration (Example: AB-1234567)
Doctor of Osteopathy (DO)
Medical Doctor (MD)
 
Psychology
  Licensed Psychologist (LP)
Limited Licensed Psychologist (LLP)
Temporary Limited Licensed Psychologist (TLLP)

 
Social Work
  Licensed Bachelor's Social Worker (LBSW)
Licensed Master's Social Worker (LMSW)
Limited Licensed Bachelor's Social Worker (LLBSW)
Limited Licensed Master's Social Worker (LLMSW)
Registered Social Service Technician (RSST)



National Provider Identification   (If applicable, enter alpha-numeric)
Population Served/Managed*
Year you started working in Human Services *       
Year you started working at your current job *     

Do you have any special requests to enable your participation in VCE events?
  Special Needs
     Hearing Impairment (Need Interpreter)
     Vision Impairment (with seeing-eye dog)
     Disabled (with caretaker accompanyment)
     Wheelchair Accessibility
     Vegetarian Meal
     Vegan Meal
     Kosher Meal
     Peanut Allergy
     Shellfish Allergy

    Other? Please specify:
    

Contractual Agreement
 
wayne county guidance center
The Detroit-Wayne County Community Mental Health Agency is a division of the Wayne County Department of Health and Human Services.

Robert A. Ficano,
Wayne County Executive
The Virtual Center of Excellence (VCE) is the Online Training Center for Detroit-Wayne County Community Mental Health Agency, managed by The Guidance Center. The Virtual Center of Excellence is a non-profit agency and receives no funding from advertising. © Copyright 2007-2010. All Rights Reserved. Site by Wit Creative / Design by Pangborn Design Ltd.

The information provided by VCE Online is designed to support, not to replace, the relationship that exists between a patient/site visitor and his/her physician.

Systems Change | About | Members | Training | Recovery | Documents | Research | Links | Contact | Privacy Policy | Sitemap | Terms of use
This page was last updated on 04/08/2010.