Psychiatric/Mental Health (PMH) Nurse Application

APPLICATION REQUIREMENTS FORPSYCHIATRIC/MENTAL HEALTH (P/MH) NURSE LISTING (CONT’D)3. Submission of one (1) of the applicable forms A (Page 9) or B (Page 10) to theBoard of Registered Nursing to satisfy the supervised clinical experience requirement.A. Verification of Supervision of Clinical Experience - Page 9Verification of two (2) years of clinical experience in providing psychiatric/mental healthcounseling services under the supervision of one or more of the following professionals withcurrent training and practice as well as a current, clear and active license: A psychiatric/mental health nurse listed with the California Board of Registered Nursing.A licensed clinical psychologist.A licensed clinical social worker.A licensed marriage, family and child counselor.A psychiatrist.The supervised clinical experience for the provision of psychiatric/mental health counselingservices may be satisfied by evidencing that the required two (2) years of clinical experiencewas completed in the following manner: One (1) year obtained while completing the master’s degree in nursing and one (1) yearafter the master’s degree in nursing had been conferred;ORTwo (2) years obtained subsequent to the conferral of the master’s degree in nursing.If one professional did not supervise the entire two (2) year period, the verification form mustbe submitted by each supervisor to evidence the completion of the required supervisedclinical experience during the two (2) year period. The two (2) year period does not need tobe consecutive years.Applicants whose experience had been acquired outside of California must provide evidencethat at the time the experience was obtained, the supervisor was currently licensed, certifiedor registered to provide psychiatric/mental health counseling services by a state agencywhose standards are equivalent to or greater than those required by the equivalent licensingagency in California.B. Verification of Psychiatric/Mental Health Certification by a NationalAssociation - Page 10American Nurses Association - American Nurses Credentialing Center (ANCC)* verificationthat the applicant is currently certified as a Clinical Specialist in Psychiatric/Mental HealthNursing. The verification form must be submitted directly to the Board of Registered Nursingby ANCC.* American Nurses Association - American Nurses Credentialing Center (ANCC)600 Maryland Ave., SW, Suite 100 West, Washington, DC 20024-2571(800) 284-2378http://www.nursingworld.org/ancc(Above Information Subject to Change)LIC-A-PMH (REV 1/19)Page 5

VIII.HONORABLY DISCHARGED MEMBERS OF THE U.S. ARMED FORCES RECEIVE EXPEDITED REVIEWNotwithstanding any other law, on and after July 1, 2016, a board within the department shall expedite, and mayassist, the initial licensure process for an applicant who supplies satisfactory evidence to the board that theapplicant has served as an active duty member of the Armed Forces of the United States and was honorablydischarged (Business and Professions Code section 115.4If you would like to be considered for this expedited review and process, please provide the followingdocumentation with your application:1. Report of Separation form.The report of separation form issued in most recent years is the DD Form 214, Certificate of Release orDischarge from Active Duty. Before January 1, 1950, several similar forms were used by the military services,including the WD AGO 53, WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD and the NAVCG 553.Information shown on the Report of Separation may include the service member's date and place of entry intoactive duty, date and place of release from active duty, last duty assignment and rank, military job specialty,military education, total creditable service, separation information, etc.LIC-A-PMH (REV 1/19)Page 6

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNORBOARD OF REGISTERED NURSINGPO Box 944210, Sacramento, CA 94244-2100P (916) 322-3350 l www.rn.ca.govAPPLICATION FOR THE LISTING AS A PSYCHIATRIC/MENTAL HEALTH (P/MH) NURSEAPPLICATION FEE - 350.00MILITARY HONORABLE DISCHARGE - Check here if you served as an active dutymember of the Armed Forces of the United States and were hoborably discharged.A. PERSONAL DATA (Please print or type):Name:(Last)Previous Names (Including Maiden Name):( First)(Middle)Address of Record:Date of Birth:( Number & Street)(City)(Month)(State)Telephone Number:Home ()B. RN LICENSURE:Work ((Zip Code)Expiration Date:Original State of RN Licensure:RN License Number:Date Issued:C. RN EDUCATION:Name of Professional Registered NursingLocation:Program:Expiration Date:(City)ADNDIPEntrance Date:BSN(Year)E-Mail Address:)California RN License Number:Date Issued:List ALL States Where You Hold/Held an RN License and Status:Type of RN Program:(Day)U.S. Social Security Number or Individual TaxpayerID Number:(State or Country)Graduation/Completion Date:MSND. PSYCHIATRIC/MENTAL HEALTH EDUCATION:Name of Psychiatric/Mental Health NursingLocation:Academic Program:(City)Entrance Date:Graduation/Completion Date:(State or Country)Nursing Specialty of Master’s Degree:E. SUPERVISED CLINICAL EXPERIENCE IN PSYCHIATRIC/MENTAL HEALTH COUNSELING:Beginning and EndingSupervisor’s Name andBriefly Describe the Nature of Your ClinicalDates:Profession:Experience and State Where It Was Obtained:LIC-A-PMH (REV 1/19)Page 7

F. PSYCHIATRIC/MENTAL HEALTH NURSE PROFESSIONAL CERTIFICATION (If Applicable):Name of Association:Original Date of Certification:Area of Specialization:Certification Number:Method of Certification:Current Renewal/Recertification Cycle Dates:ExaminationOtherG. BACKGROUND INFORMATION:I.Have you ever applied for a Psychiatric/Mental Health Nurse listing in California?If yes:Name at Time of Application: Date Submitted:YesNoII. Have you ever been issued a Psychiatric/Mental Health Nurse listing in California?YesIf yes: STOP. DO NOT CONTINUE. Please contact the Board regarding whether youshould reapply or file a petition for reinstatement of your Psychiatric/Mental Health Nurselisting.NoIII. Have you ever had a health-care related license/certificate/listing to practice nursing Yesrevoked, suspended, placed on probation or otherwise disciplined or voluntarilysurrendered in any way?If yes, please explain fully as described in the General Instructions - Section V.IV. Have you ever had a professional or vocational license/certificate/listing to practice Yesrevoked, suspended, placed on probation or otherwise disciplined or voluntarilysurrendered in any way?If yes, please explain fully as described in the General Instructions - Section V.NoNoI understand that I am required to report immediately to the California Board of Registered Nursing ANYdisciplinary action and/or voluntary surrender against ANY health-care related license/certificate/listing thatoccurs between the date of this application and the date that a California Psychiatric/Mental Health Nurselisting is issued. I understand that failure to do so may result in denial of this application or subsequentdisciplinary action against my license/certificate/listing.I certify, under penalty of perjury under the laws of the State of California, that all information provided inconnection with this application for the Psychiatric/Mental Health Nurse listing is true, correct and complete.Providing false information or omitting required information is grounds for denial of licensure/certification/listing or licensure/certification/listing revocation in California.SIGNATURE OF APPLICANT:DATE:LIC-A-PMH (REV 6/20)Page 8NOTE:PLEASE TAPE ARECENT 2” x2”PASSPORT SIZEPHOTOGRAPH

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNORBOARD OF REGISTERED NURSINGPO Box 944210, Sacramento, CA 94244-2100P (916) 322-3350 l www.rn.ca.govVERIFICATION OF THE COMPLETION OFA PSYCHIATRIC/MENTAL HEALTH (P/MH) ACADEMIC PROGRAMA. TO BE COMPLETED BY APPLICANT :Please complete Section A and forward to the program director/representativefor the Psychiatric/Mental Health nursing academic program for completion. Official transcripts submitted must include all completedcourse work with the master’s degree status conferred and must be sent directly to the Board of Registered Nursing by theRegistrar’s Office/Transcript Office. A processing fee may be required for the submission of the official transcripts. Please print ortype.Name:Previous Names (Including Maiden Name):( Last)(First)(Middle)Address:Date of Birth:(Number & Street)(Month)(Day)(Year)U.S. Social Security Number or Individual Taxpayer ID Number:(City)(State)Telephone Number:Home ()Work ((Zip Code)California RN License Number:Expiration Date:)Name of Master’s Degree Nursing Program:Entrance and Completion Dates:Specialty:Signature of Applicant: Date:B. TO BE COMPLETED BY THE PROGRAM DIRECTOR/REPRESENTATIVEPSYCHIATRIC/MENTAL HEALTH NURSING ACADEMIC PROGRAM : Please complete PartFORTHEB regarding theabove named applicant and return to the Board of Registered Nursing.Name of Master’s Degree Nursing Program:Telephone Number:()Address:(Number & Street)(City)(State)Nursing Specialty:Entrance and Completion Dates:(Zip Code)Date Master’s Degree Status ear)I certify under penalty of perjury that the documentation regarding the completion of the Psychiatric/Mental Healthmaster’s nursing academic program for the above named applicant is true and correct.Signature: Date:Title: Telephone Number:( )LIC-A-PMH (REV 1/19)Page 9

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNORBOARD OF REGISTERED NURSINGPO Box 944210, Sacramento, CA 94244-2100P (916) 322-3350 l www.rn.ca.govA. VERIFICATION OF SUPERVISION OF CLINICAL EXPERIENCE (P/MH)A. INFORMATION TO BE COMPLETED BY THE APPLICANT: Please complete Part A of the form and submit to yoursupervisor for completion. If more than one (1) supervisor supervised during the two (2) year period, the form must besubmitted by each supervisor. Please print or type.Name:(Last)(First)(Middle)California RN License Number: Expiration Date:Telephone Number: ( ) U.S. Social Security Number or ITIN:B. INFORMATION TO BE COMPLETED BY SUPERVISOR: Please complete Part B of the form regarding the abovenamed applicant and submit to the Board of Registered Nursing.Name of Supervisor: Telephone Number: ( )Address:(Number & Street)(City)(State)(Zip Code)Profession: Licensed By:License Number: Expiration Date: U.S. Social Security Number:Location of Clinical Experience:(Name of Agency)(Address)Level of Supervision Provided:Summary of the nature of cases, types of treatment and/or appropriate interventions carried out by the above namedapplicant during the specified period of supervision for the provision of psychiatric/mental health counseling services:I hereby certify under penalty of perjury that the above is true and correct and that I supervised the above named applicantin providing psychiatric/mental health counseling services to clients during the period:From: To: For: Hours Per Week .Month)(Day)(Year)(Month) (Day)(Year)(Number of)(Cumulative Hours)Signature of Supervisor: Date:LIC-A-PMH (REV 1/19)Page 10

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNORBOARD OF REGISTERED NURSINGPO Box 944210, Sacramento, CA 94244-2100P (916) 322-3350 l www.rn.ca.govB. VERIFICATION OF PSYCHIATRIC/MENTAL HEALTH (P/MH) CERTIFICATIONBY A NATIONAL ASSOCIATIONA. TO BE COMPLETED BY APPLICANT:Please complete Part A and submit to the American NursesAssociation - American Nurses Credentialing Center (ANCC) to verify your clinical specialist in psychiatric/mental healthnursing certification status. A fee is required by ANCC for processing the verification form. Please print or type.Name:Previous Names (Including Maiden Name):( Last)(First)(Middle)Date of Birth:Address:(Number & Street)(Month)(Day)(Year)U.S. Social Security Number or Individual Taxpayer ID Number:(City)Telephone Number:Home ()(State)Work ((Zip Code)California RN License Number:Expiration Date:)Name of Master’s Degree Nursing Program:Entrance and Completion Dates:Specialty:Signature of Applicant: Date:B. TO BE COMPLETED BY THE CERTIFYING NATIONAL ASSOCIATION: Please complete Part Bregarding the above named applicant and return to the Board of Registered Nursing.Name of Certifying National Association:Telephone Number:()Address:(Number & Street)Method of Certification:(City)(State)(Zip Code)CNS Certification Specialty:Certificate Number:Original Date of Certification:Current Renewal Cycle Dates for Certification/Recertification:(If not applicable, please explain.)From:To:(Month)(Year)(Month)(Year)I certify under penalty of perjury that the clinical specialist in psychiatric/mental health nursing certification statusfor the above named applicant is true and correct.Signature: Date:Title: Telephone Number:( ) (OFFICIAL SEAL)LIC-A-PMH (REV 1/19)Page 11

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNORBOARD OF REGISTERED NURSINGPO Box 944210, Sacramento, CA 94244-2100P (916) 322-3350 l www.rn.ca.govINFORMATION COLLECTION AND ACCESSThe Information Practices Act, Section 1798.17 Civil Code, requires the following information to beprovided when collecting information from individuals.Agency Name:BOARD OF REGISTERED NURSINGTitle of official responsible for information maintenance:EXECUTIVE OFFICERAddress:Telephone Number:P.O. BOX 944210, SACRAMENTO, CA 94244-2100(916) 322-3350Authority which authorizes the maintenance of the information:SECTION 30, SECTION 2732.1(a), BUSINESS AND PROFESSIONS CODEALL INFORMATION IS MANDATORY.The consequences, if any of not providing all or any part of the requested information:FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION WILL RESULT IN THEAPPLICATION BEING REJECTED AS INCOMPLETE.The principal purpose(s) for which the information is to be used:TO DETERMINE ELIGIBILITY FOR LICENSURE. YOUR U.S. SOCIAL SECURITY NUMBER/ITINWILL BE USED FOR PURPOSES OF TAX ENFORCEMENT, CHILD SUPPORT ENFORCEMENTAND VERIFICATION OF LICENSURE AND EXAMINATION STATUS. SECTION 30 OF THEBUSINESS AND PROFESSIONS CODE AND PUBLIC LAW 94-455 (42 USCA 405(c)(2)(C))AUTHORIZE COLLECTION OF YOUR U.S. SOCIAL SECURITY NUMBER/ITIN. IF YOU FAIL TODISCLOSE YOUR U.S. SOCIAL SECURITY NUMBER/ITIN, YOU WILL BE REPORTED TO THEFRANCHISE TAX BOARD, WHICH MAY ASSESS A 100 PENALTY AGAINST YOU.YOURNAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLICUPON REQUEST IF AND WHEN YOU BECOME LICENSED.Any known or foreseeable interagency or intergovernmental transfer which may be made of theinformation:POSSIBLE TRANSFER TO LAW ENFORCEMENT, OTHER GOVERNMENT AGENCIES ANDREPORTING U.S. SOCIAL SECURITY NUMBER/ITIN TO THE FRANCHISE TAX BOARD ORFOR CHILD SUPPORT ENFORCEMENT PURPOSES PURSUANT TO SECTION 30 OF THEBUSINESS AND PROFESSIONS CODE.EACH INDIVIDUAL HAS THE RIGHT TO REVIEW THE FILES ON RECORDS MAINTAINED ONTHEM BY THE AGENCY, UNLESS THE RECORDS ARE EXEMPT FROM DISCLOSURE.(Rev 1/19)1

MANDATORY REPORTERUnder California law each person licensed by the Board of Registered Nursing is a “MandatedReporter” for child abuse or neglect purposes. Prior to commencing his or her employment, andas a prerequisite to that employment, all mandated reporters must sign a statement on a formprovided to him or her by his or her employer to the effect that he or she has knowledge of theprovisions of Section 11166 and will comply with those provisions.California Penal Code Section 11166 requires that all mandated reporters make a report to anagency specified in Penal Code Section 11165.9 [generally law enforcement agencies] wheneverthe mandated reporter, in his or her professional capacity or within the scope of his or heremployment, has knowledge of or observes a child whom the mandated reporter knows orreasonably suspects has been the victim of child abuse or neglect. The mandated reporter mustmake a report to the agency immediately or as soon as is practicably possible by telephone, andthe mandated reporter must prepare and send a written report thereof within 36 hours of receivingthe information concerning the incident.Failure to comply with the requirements of Section 11166 is a misdemeanor, punishable by up tosix months in a county jail, by a fine of one thousand dollars ( 1,000), or by both imprisonmentand fine.For further details about these requirements, consult Penal Code Section 11164, and subsequentsections.(Rev 1/19)2

psychiatric/mental health nursing and complete two (2) years of supervised clinical experience in providing psychiatric/mental health counseling services. The master’s degree in nursing must be . directly related to mental health, such as psychiatric/mental health File Size: 676KB