VCEOnline - Member Registration

| VCE Annual Report 2007-08

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M E M B E R S H I P F O R M

* Indicates Required Field!

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 *


Organization Name *
Address*
Address 2
City*
State*
Zip*

Secondary Job

Organization

Organization Address


Organization Name
Address
Address 2
City
State
Zip

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 (check at least one)

Assertive Community Treatment (ACT)
Parent Management Training-Oregon (PMTO)
Family PsychoEducation (FPE)
Infant Mental Health (IMH)
Integrated Dual Diagnosis Treatment (IDDT)
Community Mental Health/Juvenile Justice/Wraparound (CMH/JJ/WRAP)
Administration
Peer Support 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 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


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