MENTAL HEALTH PROFESSIONS LICENSING BOARD 2001 Capitol Ave, Room 104 Cheyenne WY 82002 http://plboards.state.wy.us/mentalhealth
PROFESSIONAL REFERENCE Please type or print legibly, preferably in blue ink. The Board will only accept originally signed references.
To:
Mental Health Professions Licensing Board
From: Date: Applicant: The person named above has made an application to become licensed or certified as a mental health professional in the state of Wyoming. Applicants are required to demonstrate their integrity, professionalism and character in the field through professional recommendations which attest to applicants’ abilities and professional performance. Board Rules and Regulations require individuals providing professional references to have at least six (6) months of direct knowledge of such experience by the applicant. Please respond to the following questions: 1.
How long have you known the applicant?
2.
What is your relationship to the applicant?
3.
Please describe the situations in which you have observed the applicant engaged in clinical practice.
4.
Is the applicant currently engaged in clinical practice?
5.
In your opinion, does the applicant possess the personal and professional integrity to practice clinically in the mental health field?
6.
How does the applicant demonstrate respect for the client-therapist relationship?
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Yes
No (Comments?)
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No (Comments?)
Revised 8/2013
7.
How does the applicant demonstrate knowledge regarding current ethical issues in clinical mental health practice?
8.
To your knowledge, has there ever been any concern regarding this applicant’s ethical conduct?
9.
Do you have any reason to believe that this applicant should not be granted licensure or certification in a mental health profession?
Yes
No (Comments?)
10.
Do you believe that on an overall basis, including ethics, conduct, character, and competence, this applicant is or would be a credit to the mental health profession?
Yes
No (Comments?)
SIGNATURE PXVWEHVLJQHG
Yes
No (Comments?)
DATE TELEPHONE NUMBER(S):
Address:
Street Address
City
State
Business
Zip
Cell
E-mail Address: Please provide an e-mail address that you check regularly. If there are any questions or issues regarding your reference, the Board staff will communicate with you at this address.
Per Wyoming Statute § 16-4-203(d)(iv) letters of reference are not subject to the public right of inspection. Therefore, any comments that you provide will remain confidential between yourself and the Board. The signed reference may be e-mailed to
[email protected], or faxed to (307) 777-3508, or mailed to the address provided on this form.
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Revised 8/2013
