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Credentials to show in your formal title
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Website
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home - Zip
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Home Phone
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Home - Country
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Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Chad
Chile
China
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
Gabon Republic
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea Bissau
Guyana
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Republic of
Kuwait
Kyrgyzstan
Laos
Latvia
Lesotho
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakhistan
Palau
Panama
Papua New Guinea
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
South Africa
Spain
Sri Lanka
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Vanuatu
Vatican City State
Venezuela
Vietnam
Wallis and Futuna Islands
Yemen
Zambia
Preferred Mailing Address
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Office
Home
Date of Birth
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Last 4 numbers of your social security number
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Place of Birth
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Please list the State you are licensed in, license number, Date Lic/Cert, Date First Lic / Cert
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Highest Degree
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Ph.D.
Psy.D.
M.D.
D.O.
Ed.D.
M.S.
M.A.
M.S.W.
Other
Professional Identity (select all that apply)
any of selected
all of selected
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Clinical Mental Health Counselor
Clinical Psychologist
Clinical Social Worker
Counseling Psychologist
Marriage and Family Therapist
Psychiatrist
Psychiatric Nurse Practitioner
College / University
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Department
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Name of Internship Program
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Address
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Date Completed
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any date
this month
this year
last month
last year
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Accredited By
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Have you ever been convicted of a felony
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Yes
No
Have you ever been found liable for or settled a malpractice complaint
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Yes
No
Charged with an ethics or conduct violation that resulted in an adverse decision or action
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all of selected
none of selected
Yes
No
Have you ever been known by another name, if yes, please provide:
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Forensic Specializations (select all that apply)
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Child Abuse and Neglect
Child Custody/Parenting
Civil Commitment
Competence to Stand Trial
Criminal Responsibility
Disability
Domestic Abuse/Violence
Downward Departure
Fitness for Duty
Gang Violence
Harassment and Discrimination
Immigration
Juvenile Justice
Personal Injury
Sexual Violence
Substance Abuse/Addiction
Suicidal Risk Assessment
Violent Risk Assessment
Workplace Violence
Please select all "partnering organizations" you are currently a member of:
any of selected
all of selected
none of selected
None
American Mental Health Counselors Association (AMHCA)
Darsey, Black & Associates, LLC
Emerald Coast Mental Health Counselors Association (ECMHCA)
Florida Mental Health Counselors Association (FMHCA)
Licensed Professional Counselors Association of Georgia, INC. (LPCA)
LifeWorks Group
Mental Health Counselor's Association of Palm Beach (MHCAPB)
Northeast Florida Mental Health Counselors Association (NEFMHCA)
Suncoast Mental Health Counselors Association (SMHCA)
Utah Mental Health Counselors Association (UMHCA)
Vecchi Group International (VGI)
Washington Mental Health Counselors Association (WMHCA)
Please list all other professional associations you are a member of:
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CFMHE Certificate Number
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CFMHE Date Credentialed
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any date
this month
this year
last month
last year
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CCCE Credentialed Date
on or before
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any date
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this year
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CCCE Certification Number
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CFBA Credentialed Date
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any date
this month
this year
last month
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CFBA Certification number
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Work History
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Organization/Employer #1
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Inclusive Dates (Position #1)
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Address (Position #1)
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Supervisor (Position #1)
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Nature of forensic work (Position #1)
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Percentage of time spent in forensic work (Position #1)
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Organization/Employer #2
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Inclusive Dates (Position #2)
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Supervisor (Position #2)
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Nature of Forensic Work (Position #2)
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Percentage of time spent in forensic work (Position #2)
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Organization/Employer #3
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Inclusive Dates (Position #3)
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Supervisor (Position #3)
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Nature of Forensic Work (Position #3)
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Percentage of time spent in forensic work (Position #3)
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Organization/Employer #4
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Inclusive Dates (Position #4)
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Supervisor (Position #4)
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Nature of Forensic Work (Position #4)
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Percentage of time spent in forensic work (Position #4)
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Organization/Employer #5
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Supervisor (Position #5)
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Nature of Forensic Work (Position #5)
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Percentage of time spent in forensic work (Position #5)
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Organization/Employer #6
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Inclusive Dates (Position #6)
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Address (Position #6)
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Supervisor (Position #6)
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Nature of Forensic Work (Position #6)
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Percentage of time spent in forensic work (Position #6)
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Organization/Employer #7
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Inclusive Dates (Position #7)
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Address (Position #7)
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Supervisor (Position #7)
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Nature of Forensic Work (Position #7)
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Percentage of time spent in forensic work (Position #7)
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Organization/Employer #8
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Inclusive Dates (Position #8)
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Supervisor (Position #8)
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Nature of Forensic Work (Position #8)
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Percentage of time spent in forensic work (Position #8)
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If additional positions in past 10 years, email details to forensic@nbfe.net.
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List any volunteer positions in professional associations, boards, etc. and inclusive dates.
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List any publications/books you have authored in the field of mental health and/or forensics.
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List any research projects you have participated in relevant to mental health and/or forensics.
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List any other unique qualifications relevant to forensic mental health evaluation.
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Three Professional References
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Name of Reference #1
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Email of Reference #1
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Name of Reference #2
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Email of Reference #3
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Reminder: References must upload letterhead to https://www.surveymonkey.com/r/CFMHEReference
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Verification of Forensic Experience
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Type of Experience (#1)
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Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "Other" for experience #1, describe:
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Case #1 (if applicable):
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Credit Hours #1 (if a class)
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Actual Hours #1
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Comments on Experience #1
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Type of Experience (#2)
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Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #2, describe:
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Case #2 (if applicable)
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Credit Hours #2 (if a class)
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Actual Hours #2
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Comments on Experience #2
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Type of Experience (#3)
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Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #3, describe:
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Case #3 (if applicable)
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Credit Hours #3 (if a class)
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empty
not empty
begins with
ends with
Actual Hours #3
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #3
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Type of Experience #4
is
is not
Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #4, describe:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Case #4 (if applicable)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Credit Hours #4 (if a class)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Actual Hours #4
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #4
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Type of Experience #5
is
is not
Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #5, describe:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Case #5 (if applicable)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Credit Hours #5 (if a class)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Actual Hours #5
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #5
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Type of Experience #6
is
is not
Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #6, describe:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Case#6 (if applicable)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Credit Hours #6 (if a class)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Actual Hours #6
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #6
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Type of Experience #7
is
is not
Forensic Evaluation
Training Seminar/Course/Workshop
Court Testimony
Other
If "other" for experience #7, describe:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Case #7 (if applicable)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Credit Hours #7 (if a class)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Actual Hours (#7)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #7
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Type of Experience #8
is
is not
Forensic Evaluation
Training Course/Seminar/Workshop
Court Testimony
Other
If "other" for experience #8, describe:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Case #8 (if applicable)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Credit Hours #8 (if a class)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Actual Hours (#8)
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Comments on Experience #8
contains
is
does not contain
is not
empty
not empty
begins with
ends with
If you need more space to document the 40 hours, email additional experiences to forensic@nbfe.net
contains
is
does not contain
is not
empty
not empty
begins with
ends with
By marking "I agree" below and affixing my initials, I agree that:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
I voluntarily apply to the NBFE for certification as a Certified Forensic Mental Health Evaluator.
is
is not
Agree
Disagree
My application is subject to the rules, bylaws, and other governing provisions of NBFE.
is
is not
Agree
Disagree
I agree to be bound by the regulations of NBFE both as a candidate and once certified.
is
is not
Agree
Disagree
I agree to be bound by the ethical codes/guidelines of my profession (choose your discipline):
is
is not
Counselors: American Mental Health Counselors Association or American Counseling Association
MFTs: American Association of Marriage & Family Therapy
Social Workers: National Organization of Forensic Social Work and NASW
Psychologists: American Psychological Association/American Board of Forensic Psychology
Psychiatrists: American Psychiatric Association and American Academy of Psychiatry and the Law
Nurse Practitioners: American Nursing Association/International Association of Forensic Nurses
I agree to follow current American Psychological Association guidelines for child custody matters.
is
is not
Agree
Disagree
I agree to surrender my certification/candidacy if found in violation of the above by NBFE.
is
is not
Agree
Disagree
I recognize that NBFE may decide that I am not qualified, and I agree to abide by that decision.
is
is not
Agree
Disagree
I authorize NBFE to make inquiries to the following to investigate my qualifications:
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Professional references I listed above and/or who sent letters of recommendation to NBFE
is
is not
Yes
No
Professional associations that have current or past memberships with
is
is not
Yes
No
Current or previous employers
is
is not
Yes
No
Licensing or certification boards
is
is not
Yes
No
Any/all other relevant parties or entities I have referenced in the course of my application
is
is not
Yes
No
I invite anyone contacted by NBFE to respond freely/frankly without fear of claim of damages by me.
is
is not
Yes
No
I know I will not receive exam study/prep materials until after submitting my certification fee.
is
is not
Yes
No
I understand NBFE reserves the right to change its schedule of fees at any time during my candidacy.
is
is not
Yes
No
I'm aware that if I've been disciplined by my licensure board, I may be ineligible for certification
is
is not
Yes
No
I understand that I have 90 days from my application date to complete the written exam.
is
is not
Yes
No
I understand that I will have 6 months to prepare for the oral exam after passing the written exam
is
is not
Yes
No
I know NBFE may assess an extra fee if I do not schedule the oral exam within that 6-month period.
is
is not
Yes
No
If certified, I agree to pay the required annual renewal fee assessed by NBFE.
is
is not
Yes
No
I understand that all fees associated with the application and renewal process are non-refundable.
is
is not
Yes
No
By typing my name, I attest that the information I submitted in this application is accurate.
contains
is
does not contain
is not
empty
not empty
begins with
ends with
I consent to NBFE video/audio recording my oral exam for scoring purposes.
is
is not
Yes
No
By affixing my initials, I agree that my typed name has the same legal effect as signing under oath.
contains
is
does not contain
is not
empty
not empty
begins with
ends with
Date of Signature:
on or before
is
on or after
empty
any date
this month
this year
last month
last year
is not
My current state license(s) to practice as a mental health professional
any of selected
all of selected
none of selected
Yes
No
My professional resume or CV
any of selected
all of selected
none of selected
Yes
No
Verification of membership in professional associations (if applicable)
any of selected
all of selected
none of selected
Yes
No
Not Applicable
Proof of my current malpractice liability insurance policy
any of selected
all of selected
none of selected
Yes
No
I uploaded a current/recent face shot of myself (color photo) to my member profile at www.nbfe.net
any of selected
all of selected
none of selected
Yes
No
I asked 3 colleagues to upload reference letters to https://www.surveymonkey.com/r/CFMHEReference
any of selected
all of selected
none of selected
Yes
No
Note: Reference letters must be written by mental health professionals only.
contains
is
does not contain
is not
empty
not empty
begins with
ends with
I understand the above letters must attest to my ethical/moral standards & clinical skills/abilities
any of selected
all of selected
none of selected
Yes
No
or
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Copyright © 2017
National Board of Forensic Evaluators, Inc.
All Rights Reserved
Office (386) 366-5761
Hours of operations:
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595 W Granada Blvd., Suite H
Ormond Beach, FL 32174
Administrative Assistant
Credentialing/Continuing Education
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Valentino Travieso
Valentino@nbfe.net
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