Forms

Any of the following forms can be printed for your use.  PDF files require acrobat reader.  You can get the latest version of Acrobat Reader by clicking on the image below:

 

Change of Address  
Board rules require that a licensed behavioral health professional report any change of address to the agency office within 30 days of the change.  The Board does NOT accept changes by phone or e-mail.  You must submit changes in writing on a form provided by the Board. (see R4-6-205)

Inactive Request Form
A professional can place their license on inactive status for one renewal period. (See R4-6-305)

Extension to Inactive Request Form
A professional can request an extension of the inactive status by showing good cause.  (See R4-6-209)

Reassessment  
An applicant who is found ineligible may submit a request for reassessment of the application within 12 months of the notice of ineligibility. (see R4-6-303)

Complaint  
Filing this form initiates a complaint against a behavioral health professional certified by this Board.  (see R4-6-1001.A)

Public Records Request  
Copies of public information can be requested by submitting this completed form including fee.  (see R4-6-207)

Self-query instructions   
This form explains how to obtain your required data bank reports.

Credentialing Committee members and agency staff CANNOT approve any required documentation prior to receipt of an application.