Mental Health Professional/Mental Health SpecialistInstructionsThis form should be used to request acknowledgement of Mental Health Professional/Child Mental Health Specialist qualifications, while working at a licensed behavioralhealth agency, as required by WAC 246-341-0515.RequirementsFF Complete Mental Health Professional (MHP)/Child Mental Health Specialist(CMHS) acknowledgement request formFF Attach all supporting documents as indicatedFF Email completed request with all supporting documentation to the Department ofHealth (DOH) at [email protected] ChecklistFF Indicate whether you are requesting acknowledgement of meeting therequirements for MHP, Child MHS, or both.FF Indicate if you are requesting acknowledgement via DOH designation oragency attestation. If requesting via agency attestation, only fill outsections 1-3 of this application. If requesting via DOH designation, you willneed to fill out all sections of this application.FF 1. Demographic InformationLegal Name: List your full name: first, middle, and last.Birth Date: Provide the month, day, and year of your birth.Email: Enter your email address, if you have one.Credential Number: List your DOH credential number.FF 2. Agency InformationAgency Name: List the agency name.Agency Credential Number: Provide the credential number of the agency.Agency Email: Enter an email address for the agency.Agency Address: List the agency’s physical address.FF 3. Agency Attestation: Fill out this section ONLY if the agency is attesting thatthe agency has verified the applicant meets all of the requirements for the MHP/MHS being requested. If this section is completed, no additional sections of thisapplication are required to be completed. Please note, DOH may verify that theagency attested correctly during routine on-site surveys.DOH 611-014 January 2022Page 1 of 2

FF 4. MHP Qualifications Fill out this section only if the agency is not attesting insection 3, and you are requesting DOH MHP acknowledgementRequired Documentation attached for review for MHP: College/university diploma or transcripts with degree and graduation date postedFF 5. Child MHS Qualifications: Fill out this section only if the agency is not attestingin section 3, and you are requesting MHS acknowledgementRequired Documentation attached for review for Child MHS: Specialist Training Documentation and Hours Documentation of supervised hours by a Child MHSFF 6. Supervised Experience by MHP: Provide MHP name and hoursFF 7. Supervised Experience by Child MHS: Provide Child MHS name and hoursFF 8. Applicant’s Attestation: Sign and date this section if applying by DOHdesignation.In order to process your request:Please mail or email your documentation to:Mental Health Professional Credentialing SectionP.O. Box 47877Olympia, WA 98504-787[email protected] 611-014 January 2022Page 2 of 2

DateStampHereMental Health ProfessionalP.O. Box 47877Olympia, WA 98504-7877360-236-4700Mental Health Professional/Mental Health SpecialistI am requesting acknowledgement that I meet the requirements for:FFMental Health Professional (MHP) and/orFFChild Mental Health SpecialistFFI am requesting DOH designationFFI am requesting acknowledgment via Agency Attestation-or-1. Demographic InformationName: FirstBirth Date (mm/dd/yyyy)MiddleLastEmail AddressCredential Number2. Agency InformationAgency NameAgency Credential NumberAgency Email AddressAgency Mailing AddressCityStateZip CodeCounty3. Agency AttestationI certify that I am an agency representative and have verified that the individual named above meets allexperience and credentialing requirements for the designation(s) indicated on this application.Signature of Agency Representative: Today’s Date:Print Name:Signature of Applicant: Today’s Date:Print Name:DOH 611-015 January 2022Page 1 of 3

4. MHP QualificationsI am:(Check all qualifications that apply and attach supporting documentation)FAF psychiatrist, psychologist, psychiatric nurse or social worker as defined in chapters 71.05 RCW and 71.34RCW;FAF person who is licensed by the Department of Health as a Mental Health Counselor, Mental Health CounselorAssociate, Marriage and Family Therapist or Marriage and Family Therapist Associate;FAF person who is registered by the Department of Health as an Agency Affiliated Counselor who has a master’sdegree or further advanced degree in counseling or one of the social sciences from an accredited college or university. In addition, I have at least two years of experience in direct treatment of person(s) with mental illness oremotional disturbance, such experience gained under the supervision of a mental health professional recognizedby the department or attested to by the licensed behavioral health agency.5. Child MHS Qualifications as defined in RCW 71.34.020(Attach supporting documentation)Training Completion DateSubjectTraining HoursDOH 611-015 January 2022Page 2 of 3

6. Supervised Experience by Mental Health ProfessionalName of SupervisorNumber of Hours7. Supervised Experience by Child Mental Health SpecialistName of SupervisorNumber of Hours8. Applicant AttestationI certify that I meet the criteria as indicated above. I have attached the required documentation regardingmy education, experience, and supervision:Signature of Applicant:Today’s Date:Print Name:DOH 611-015 January 2022Page 3 of 3

Child Mental Health Specialist qualifications, while working at a licensed behavioral health agency, as required by WAC 246-341-0515. . Mental Health Professional Credentialing Section P.O. Box 47877 Olympia, WA 98504-7877 HSQACredentia[email protected] DOH 611-014 January 2022 Page 2 of 2. Date Stamp