NEW APPLICANT STATUS APPLICATION INTENT TO APPLY …...March 2019 Intent to Apply to Become a Page 3...

March 2019 Intent to Apply to Become a of 18

DVOMB Approved Provider

NEW APPLICANT STATUS APPLICATION

INTENT TO APPLY

TO BECOME A DVOMB

APPROVED PROVIDER

COLORADO DOMESTIC VIOLENCE OFFENDER MANAGEMENT BOARD

COLORADO DEPARTMENT OF PUBLIC SAFETY

DIVISION OF CRIMINAL JUSTICE

700 Kipling Street, Suite 3000

Denver, CO 80215

Tel: (303) 239-4528 or 1-800-201-1325 (in Colorado only)

Fax: (303) 239-4223

http://dcj.dvomb.state.co.us

http://dcj.dvomb.state.co.us/



TABLE OF CONTENTS

Part I – For Applicant Information for Intent to Apply .....................................................................................................................3

Instructions .....................................................................................................................................................4

Frequently Asked Questions ..........................................................................................................................5

Checklist of Documents to be Submitted.......................................................................................................6

A. Background and Identifying Information ..............................................................................7

B. Certification and Licensure ....................................................................................................9

C. DORA Verification ................................................................................................................10

D. Criminal Background Information .........................................................................................11

E. Authorization for Release of Information – Background check ............................................12

F. Agreement to Notify the DVOMB of New Civil Disputes Involving Domestic Violence ...12

G. Statement of Understanding ...................................................................................................13

H. Statement of Compliance ......................................................................................................14

I. Research Statement of Compliance ......................................................................................14

J. Administrative Policies Statement of Compliance ...............................................................14

K. Education ..............................................................................................................................15

L. DV Clinical Supervision Agreement ....................................................................................16

Part II – For DV Clinical Supervisor

M. DV Clinical Supervision Agreement ....................................................................................16

N. Verification of Ongoing Clinical Supervision ......................................................................17

O. Verification of Ongoing Co-Facilitation ...............................................................................17

P. Letter from Victim Advocate ................................................................................................18

Q. Supervisor Verification ..........................................................................................................18



PART I – FOR APPLICANT

Information for Intent to Apply Who should fill out this application?

This application is for individuals who want to begin the process of becoming a DVOMB Approved Provider.

Applicants apply as individuals; not partnerships, agencies or programs. Applicants regardless of their credentials

must complete all information in this form and receive approval from the Application Review Committee (ARC)

prior to beginning any co-facilitated services to court-ordered domestic violence offenders.

Applicants must demonstrate that they meet the qualifications of, and will comply with, standards of practice

contained in the Standards for Treatment with Court Ordered Domestic Violence Offenders published by the

Domestic Violence Offender Management Board (hereafter referred to as the Standards). It is the applicant’s

responsibility to ensure reference and use the most current version of the Standards.

It is important to note that the acceptance of this application by the ARC is conditional and does not grant you

placement on the Approved Provider List. Once you have completed all of the requirements of your desired level

of approval, then you must submit the corresponding application in order to seek approval.



Instructions

Prior to submission, please ensure your application adheres to the below.

1. DO NOT alter any part of this application.

2. ONLY submit the information requested; do not included any unrequested, supplemental information.

3. Submit the required information in the order requested.

4. DO NOT use staples, paper clips, binders, sheet protectors, or other materials.

5. Submit all materials on SINGLE-SIDED COPIES.

6. Remove pages 2-5 prior to submitting.

7. All applicants involved in domestic violence offender services must have a Full Operating Level or Domestic

Violence Clinical Supervisor (DVCS) Approved Provider as a co-facilitator until approval from the Board is

granted as a DVOMB Approved Provider.

8. All applicants must have supervision in accordance with the Standards. All applicants must have entered into a

contractual agreement with an approved DVCS in good standing with the Department of Regulatory Agencies

(DORA) and the DVOMB.

9. Applicants must electronically submit one set of fingerprints for the purpose of a background check of their

criminal history. To do so, go to the Identogo website here: https://uenroll.identogo.com/workflows/25YGT4.

Enter your personal information and schedule an appointment at one of the approved fingerprint center

located near you. You will receive confirmation of your appointment. Payment is made at the time of

fingerprinting for a total of $49.50. Business checks, credit cards, and money orders are accepted. Personal

checks will NOT be accepted. You can also schedule an appointment by phone by calling the toll free number

1-(844) 539-5539. When calling, you must supply the DVOMB Service Code: 25YGT4. If you have

questions, please email Adrienne Corday, Program Assistant to the DVOMB at [email protected]

10. Please keep a copy of your completed application for your records.

Please note the Standards are a living document and the DVOMB makes changes and updates

regularly. It is the responsibility of the applicant to ensure the most current version of the

application is being utilized.

https://uenroll.identogo.com/workflows/25YGT4

mailto:[email protected]



Frequently Asked Questions

How can an applicant prepare for completing this application?

An applicant should first read and understand the new 9.0 Standards before completing this packet.

Applicant may follow along using the new 9.0 Standards to clarify application requirements. Applicants

will also need to meet with their DVCS in order to complete the application.

Where can additional copies of the Standards and application forms be found?

Additional copies of the Standards and application materials may be obtained by calling

(303) 239-4528. They are also available at: https://www.colorado.gov/pacific/dcj/dvomb-standards

What should an applicant do upon completion of this application?

When completed, send application, required attachment materials, and money order in hard copy to: Domestic Violence Offender Management Board/Division of Criminal Justice, 700 Kipling Street, Suite 3000, Denver, CO 80215. Applicants may also choose to email application materials to:

[email protected] and mail their money order separately. If emailed, please request

aconfirmation of receipt.

How long will the entire application review process take?

The Application Review Committee (ARC) will usually review your application within one to two

months of receipt. You can expedite the process by submitting all of your application materials at one

time and in the required order. (Note: If your packet is incorrect or incomplete, this slows down the

approval process; the committee will notify applicants of any missing or incomplete materials).

What if an applicant has questions or needs more information?

For questions, contact the Office of Domestic Violence Offender Management at (303)-239-4528, or

contact Carolina Thomasson directly at [email protected]

How will compliance with the Standards be assured?

Compliance with the Standards will be assessed through biennial reapplications and Standards

Compliance Reviews. Additionally, other oversight and technical assistance mechanisms are available to

assist with and enhance compliance with the Standards.

https://www.colorado.gov/pacific/dcj/dvomb-standards





Checklist of Documents to be Submitted

☐ Application Pages 6-18

☐ B – Copy of DORA Registration, Licensure or Certification

☐ Da – Any explanation/documentation regarding legal history

☐ G – College Transcript

☐ K – Treatment Victim Advocate Letter

☐ A money order for $50.00 made payable to Colorado Department of Public Safety must be included for the processing of your application.

☐ Any additional documents (i.e. explanation of legal history, relevant court documentation, disciplinary action by DORA, variance request, etc).



A. Background and Identifying Information

This application is for individuals applying to gain co-facilitation hours with (please check

all that apply): ☐ Male ☐ Female ☐ LGBT+

Information provided on this application will be used by staff to conduct a criminal history check, background

investigation and to document qualifications.

Date Completing Application: __________________________________________________________________

Applicant First, Middle, and Last Name:

(You must apply as an individual, not as a program or partnership. Your name must be identical to what is listed

on your DORA listing.)

Maiden Name/Other Names Used: ___________________________________________________________

Salutation: (Mr., Ms., etc)._______________ Date of Birth: _____________________

Cell Phone Number:

E-mail Address: _______________________________________________________________________□ DO NOT PUBLISH my email on the Approved Provider List.

Please list languages (other than English) in which you provide DV treatment:

Please list for #1 AGENCY (below) your PRIMARY office where you wish correspondence to be mailed to you:

#1 AGENCY: _____________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

_________________________________________________________________________________________________

City County Zip

Main Office Phone Number: ____________________________________ Fax Number: ____________________________

Judicial District # ___________________________________________________________________________________

□ The mailing address I have listed above is my home address and should not be posted on the Approved Provider List.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

#2 AGENCY: _____________________________________________________________________________________

Address:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

City County Zip

Phone Number: _____________________________________ Fax Number: ____________________________________


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

https://www.courts.state.co.us/Jury/District/Choose.cfm



#3 AGENCY: _____________________________________________________________________________________

Address: _________________________________________________________________________________________

_________________________________________________________________________________________________

City County Zip



- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

#4 AGENCY: _____________________________________________________________________________________

Address:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

City County Zip


Judicial District # ____________________________________________________________________________________



B. Certification and Licensure

Do you have a current Colorado license, certification or registration from the Department of

Regulatory Agencies to practice psychotherapy?

YES; If yes, please provide a copy of your DORA registration/s in submitting your application.

NO; If no, you do not qualify to apply to become a DVOMB Approved Provider at this time.

If yes, please indicate type:

LCSWC CAC I LMFTC

LCSW CAC II LMFT

LPCC CAC III Registered Psychotherapist

LPC LAC Other (please specify):

Psychologist Candidate Licensed Psychologist

Have you practiced psychotherapy without a license in any other state? YES NO

If yes, please list those states: __________________________________________________________________

Have you ever been licensed or certified to practice psychotherapy in any other states? YES NO

If yes, please list those states and your license ____________________________________________________

Are there currently any pending complaints against your license, certification or registration through

any licensing or certifying body or professional organization? YES NO

If yes, please explain: ________________________________________________________________________

Have you ever been disciplined and/or found to engage in unethical behavior by any licensing or

certifying body or professional organization? YES NO


Have you ever had a license or certification revoked, suspended, renewal refused, or been placed on

probationary status by any professional licensing body? (This includes any previously successful or

currently pending challenge to your licensure, certification or registration.) YES NO


Have you ever voluntarily relinquished a license or certification to provide psychotherapy, or

voluntarily or involuntarily terminated any mental health staff privileges? YES NO




C. DORA Verification

DEPARTMENT OF REGULATORY AGENCIES (DORA)

VERIFICATION FORM

*****************************************************************************************

___________________________________________________________________________________________________________

PRINT NAME Last First Middle (Maiden Name)

___________________________________________________________________________________________________________

ADDRESS Street City State Zip

*****************************************************************************************

I hereby authorize the Department of Regulatory Agencies to release information regarding the status of my

license, registration and/or certification, complaints, and any disciplinary actions.

Signature of Applicant: ____________________________________________ Date: ___________________



D. Criminal Background Information

Have you ever been convicted of, received a deferred judgment for, or pled nolo contender to any

offense involving criminal sexual or violent behavior? YES NO

If yes, please explain: _______________________________________________________________________

Have you ever been arrested, charged or convicted of any criminal offense? YES NO

If yes, on separate pages include: 1) statement of criminal offense

Have you ever been convicted of a felony? YES NO


Have you ever been the victim or protected party in a domestic violence related protection order, legal

or civil? YES NO




E. Authorization for Release of Information – Background

check

Signature of Applicant Date

F. Agreement to Notify the DVOMB of New Civil Disputes

Involving Domestic Violence

I, _____________________________ hereby agree to notify DVOMB Staff of any civil dispute involving an

underlying factual basis of domestic violence, in order for the Application Review Committee to review and

determine the ability to practice or continue to practice under these Standards.

Signature of Applicant: ____________________________________________ Date: ___________________

Name of Applicant (type or print legibly): _______________________________________________________

I, _______________________________, authorize and consent to have a comprehensive background investigation made as to my moral character, professional reputation and fitness to be on the Domestic Violence Offender Management Board’s Provider List as an applicant working towards an Approved Provider status. I agree to give any further information that may be required in reference to my past record. I authorize and request every person, hospital, clinic, government agency (local, state, federal or foreign), court association, or institutions having possession of any documents, records or other information pertaining to me, to furnish to the Domestic Violence Offender Management Board such information, including, but not limited to, documents and records, informal, pending or closed, or any other pertinent data and to permit the Domestic Violence Offender Management Board or any of its designated officers, committees, or staff to inspect and make copies of such documents, records and other information in connection with this application

The foregoing authorization for release of information or records does not include consent for release of personal financial records, bank accounts, loans or other such personal information not related to my moral character, professional reputation, or fitness as an applicant working towards an Approved Provider status. I hereby release, discharge and exonerate the Domestic Violence Offender Management Board, its agents and representatives, and any person furnishing such information from any and all liability of every nature and kind arising out of the furnishing of such information to other medical or professional societies or organizations, hospitals and hospital committees, and government agencies in the event that other such organizations and agencies present to the Domestic Violence Offender Management Board a release of authorization for release of information executed by me or a facsimile of such release or authority executed by me.

March 2019 Intent to Apply to Become a of

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G. Statement of Understanding

I understand that the information I have submitted for this application to the Domestic Violence Offender

Management Board (hereafter Board) to begin training to become a DVOMB Approved Provider, allows for the

DVOMB and Staff to perform the following:

1. Conduct a criminal history check and a background investigation.

2. Create and disseminate a list of Applicants seeking placement on the Approved Provider List.

3. Create a database of information on the availability of domestic violence offender treatment services in

Colorado.

4. Application materials will become record at the Division of Criminal Justice and some parts may be

subject to the open record act requests pursuant to §24-72-304 C.R.S.

5. Release information regarding the status of my application and any information regarding any decision

to deny me placement on the Approved Provider List to all referring agencies.

6. This application may be re-reviewed and temporarily suspended in the event of a complaint being filed

against my person, until a final disposition by DORA is made.

7. By applying for approval, I agree to be subject to possible Standards Compliance Reviews for

compliance with the Standards when necessary.

8. Any applicant who is denied approval of intent to apply, may request reconsideration of the ARC and

appeal the decision to the DVOMB. Reference: Standards, Appendix D Appeals Process.

9. If my name is included erroneously on the Approved Provider List, the Board may remove it without

due process.

10. Inclusion on the Applicant List does not constitute approval as a DVOMB Provider, certification or

licensure and should not be represented as such. It does not create an entitlement or guarantee that I will

receive referrals. If I am approved to be on the Approved Provider List, it means that I am eligible to be

considered for referral as a provider of services for court ordered domestic violence offenders, pursuant

to §16-11.8-104, C.R.S. which states:

On or after January 1, 2001, the Department of Corrections, the Judicial Department, the Division of

Criminal Justice within the Department of Public Safety, or the Department of Human Services shall not

employ or contract with and shall not allow a domestic violence offender to employ or contract with any

individual or entity to provide domestic violence offender treatment evaluation or treatment services

pursuant to this article unless the individual or entity appears on the approved list developed pursuant to

§16-11.8-103(4), C.R.S

Signature of Applicant: ____________________________________________ Date: __________________

Name of Applicant (type or print legibly): _______________________________________________________


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H. Statement of Compliance

I have read and understand the Standards for Treatment with Court Ordered Domestic Violence Offenders in

their entirety and agree to comply with the Standards, and stay up to date with Standards changes as they arise.

I have answered all questions on this application fully and my answers are complete and true to the best of my

knowledge. I further understand that false statements or material misstatements in this application are cause for

denial of approval to be listed on the DVOMB website.

Signature of Applicant: ____________________________________________________________________

I. Research Statement of Compliance

I agree to provide data and documentation as requested by the Domestic Violence Offender Management Board

for the purposes of research or evaluation as required by Standards, Section 9.01, H


J. Administrative Policies Statement of Compliance

I agree to comply with all requirements outlined in the DVOMB Administrative Policies.



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K. EducationReference the Standards 9.01 1 (A)

Applicant must have a Baccalaureate Degree or higher in a behavioral science with, training and experience as a

counselor or psychotherapist. The degree must be obtained from a college or university accredited by an

agency recognized by the U.S. Department of Education.

Directions for Applicant:

Submit a copy of your transcript(s) in addition to completing this form. Unofficial copies are acceptable.

Applicant Name: __________________________________________________________

Degree: ____________________________ Major: _______________________________

Date Obtained: ____________________________________________________________

College or University Name: ___________________________________________________


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L. Applicant Contract Statement of ComplianceThe new applicant shall submit and include a supervision agreement co-signed by their approved DVCS. I, the

applicant and my DV Clinical Supervisor have entered into a Clinical Supervision Contract with a minimum of

the information contained in the new 9.0 Standards section 9.05, VII. We have agreed to comply with this

contract in its entirety. All questions regarding all required items in this DVCS Contract have answered prior to

signing it. I further understand that violations of the DV Clinical Supervision Contract may be cause

administrative action by DORA, the DVOMB or both.

I acknowledge that my DV Clinical supervisor may be contacted by the DVOMB or the staff of the DVOMB

for the purposes of processing this application and any other DVOMB related business. I further acknowledge

that all application related correspondence may also be copied to my DV Clinical Supervisor.


PART II – For DV Clinical Supervisor

Requirements and Information for DV Clinical Supervisors

The following portions of this application will need to be completed by the applicant’s DVCS. As a DVCS, the

DVOMB values your expertise, perspectives and feedback regarding this applicant. Therefore, applicants are

required to have a DVCS involved in their training, experience, and application to the DVOMB for placement

on the Approved Provider List. Applicants are required to receive supervision, guidance, competency assessment

and evaluation from their DVCS. Collaboration with probation officers and victim advocates shall also be

included in the applicant’s training and experience. DVCS may require applicants to obtain verification from

other supervisors for their previously completed trainings or experiential hours. DVCS shall notify the DVOMB

immediately in writing if you discontinue your DV clinical supervision with this applicant for any reason.

M. DV Clinical Supervision Contract Statement of ComplianceReference New 9.0 Standards Section 9.05, VII

The new applicant shall submit and include a supervision agreement co-signed by their approved DVCS. I, the

DVCS and the applicant of record on this application, have entered into a Clinical Supervision Contract with a

minimum of the information contained in the new 9.0 Standards section 9.05, VII. We have agreed to comply

with this contract in its entirety. All questions regarding all required items in this DVCS Contract have

answered prior to signing it. I further understand that violations of the DV Clinical Supervision Contract may be

cause administrative action by DORA, the DVOMB or both.

Signature of DVCS: __________________________________________________________


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N. Verification of Ongoing Clinical Supervision

I, ___________________________________________ do hereby verify that I meet the qualifications of

(DVCS)

DV Clinical Supervisor as required by the Standards, Section 9.05. I further verify that I am providing and

will continue to provide supervision for _____________________________________until DVOMB approval is

(Applicant)

gained as required by the Standards, Section 9.0 for the appropriate level of approval. If our supervision ends, I

will notify the DVOMB in writing immediately, with the date when supervision is terminated.


O. Verification of Ongoing Co-FacilitationReference the Standards, Section 9.01, II. (B)

Court ordered domestic violence offender treatment shall only be provided by an Approved Provider. Therefore,

while an applicant is in training and/or application process, all client face-to-face contacts must be co-facilitated

with a Full Operating Level Approved Provider or a DV Clinical Supervisor. This includes individual sessions,

group sessions, evaluations, MTT meetings, treatment plan reviews, etc. §16-11.8-104 C.R.S.

I, ___________________________________________, do hereby verify that I am co-facilitating all domestic

(FOL Treatment Provider or DVCS)

violence offender treatment and evaluation, as required, with_________________________________________.

(Applicant Name)

I further verify that I will continue to provide co-facilitation for this applicant during their entire application

process, which I understand may continue for several months or longer. If I need to discontinue my co-

facilitation, I will notify the DVOMB office at 700 Kipling Street, Suite 1000, Denver, CO 80215, immediately.

Signature of DVCS or FOL Provider: __________________________________________________________



P. Letter from Victim Advocate

As part of this application, submit a signed letter from your victim advocate verifying that he/she will be

providing victim advocacy for you as per the Standards, Section 7.02

Q. Supervisor Verification

I, __________________________________, do verify that I have reviewed all requirements for trainees in the new 9.0

(DV Clinical Supervisor’s Name)

Standards, and that this applicant has met all requirements. I also agree to assess this trainee’s competencies and

to follow the DV Clinical Supervision Contract. I agree to inform the DVOMB immediately if I discontinue DV

Clinical Supervision with this trainee for any reason. I also endorse this applicant to begin training under the

DVOMB Standards.


Date: ___________________________________________________________________________________

NEW APPLICANT STATUS APPLICATION INTENT TO APPLY …...March 2019 Intent to Apply to Become a Page 3...

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