CTR079202_Individual_Provider_Info_James_Bush.pdf

TAP Provider Contract Application Attachment 1 - Individual Provider Information

Complete a separate form for each individual that will provide services under your contract (must have at least one).

SECTION 1 - GENERAL INFORMATION

CONTRACTOR:___________________________________________________________________________________

PROVIDER NAME__________________________________________________________________________________ First Middle Last

ADDRESS________________________________________________________________________________________ City State ZIP

PHONE:_______________________ FAX: _________________________ EMAIL_______________________________

Select One: Licensed Provider Associate Counselor Clinical Supervisor

SECTION 2 - MINIMUM ELIGIBILITY REQUIREMENTS

Licensed Provider

Provider is licensed in behavioral health in the State of Arizona (Psychologist, PhD, LPC, MFT, LISAC, or LCSW), and has participated in a minimum of 3 of 6 DPG-provided problem gambling specific clinical supervision calls1 (required).

Select at least ONE of the following:

Provider holds valid NCGC II certification.

Provider has documentation verifying completion of Phase I of Core Training AND providing TAP services under the clinical supervision (8 hrs. annually) with a DPG-approved Clinical Supervisor.

Provider has documentation verifying completion of all core training2 hours (Phase I & II) and performance of 100 hours of DPG reimbursed TAP services.

Associate Counselor Provider is a licensed behavioral health counselor in the State of Arizona (LAC, LASAC, LMSW, LAMFT) (required).

Provider must provide treatment under a DPG-approved contracted provider (required).

Provider has documentation verifying completion of Phase I of Core Training (required).

Provider will participate in monthly, gambling-specific supervision (required).

Clinical Supervisor. Select at least ONE of the following:

Provider is licensed in behavioral health in the State of Arizona (Psychologist, PhD, LPC, MFT, LISAC, or LCSW).

Provider has performed 200 hours of DPG-reimbursed TAP services and completed 6 hours of training on gambling-specific clinical supervision.

Provider holds a valid International Gambling Counselor Certification Board Approved Clinical Consultant (BACC) credential.

SECTION 3 - LICENSES, CERTIFICATIONS, and TRAINING Attach copies of all licenses, certifications, and training as described in the minimum eligibility requirements section.

2 Phase I consists of 30 hours of problem gambling specific training addressing the counseling domain areas of general knowledge of problem/pathological gambling (6 hours), assessment of gambling behaviors (6 hours), individual and group therapy techniques (12 hours), and financial aspects of gambling treatment (6 hours).

Phase II consists of 30 hours of problem gambling specific training addressing the counseling domain areas of family/affected person issues (12 hours), case management (6 hours), legal issues (6 hours), and special populations (6 hours).

1 Clinical consultation supervision calls can be used to fulfill the 8 hours of clinical supervision IF specific case consultations are brought up and discussed by the provider.

TAP Provider Contract Application Attachment 1 - Individual Provider Information 1

Docusign Envelope ID: 153C6C5E-F9AB-41D6-95A8-37CD53AA61DE

James Bush info@myndhack.com

X

4480 W Peoria Glendale, AZ

708-526-8371

7082435519

Myndhack

TAP Provider Contract Application Attachment 1 - Individual Provider Information

Have you ever voluntarily surrendered a license or certificate? YES NO If yes, please explain:

Have any of your licenses or certificates ever been revoked? YES NO If yes, please explain:

Have any of your licenses or certificates ever been suspended? YES NO If yes, please explain:

SECTION 4 - SERVICE LOCATION

List below the location(s) where services will be provided by this provider.

ADDRESS________________________________________________________________________________________

CITY__________________________STATE_______________________________ZIP___________________________

ADDRESS________________________________________________________________________________________

CITY__________________________STATE_______________________________ZIP___________________________

ADDRESS________________________________________________________________________________________

CITY__________________________STATE_______________________________ZIP___________________________

ADDRESS________________________________________________________________________________________

CITY__________________________STATE_______________________________ZIP___________________________

TAP Provider Contract Application Attachment 1 - Individual Provider Information 2

Docusign Envelope ID: 153C6C5E-F9AB-41D6-95A8-37CD53AA61DE

4480 W Peoria

Glendale

AZ

85302

Council on Compulsive Gambling of NJ

NJ 30-Hour Disordered Gambling Training

This certi�cate is awarded to

James Bush

For completing 30-hour equivalent training 30 CEU hours re-certi�cation for CCS and CPS credentials 30 CEU hours for License Renewal for the following NJ Licenses: LPC, LAC, LMFT, LAMFT 15 CEU hours re-certi�cation for CADC Credentials 15 CEU hours for License Renewal for the LCADC This training is also approved for certi�cation for IGCCB CEU Approval number "IGCCB Preferred Provider"

Issued: 2025-09-03 Expires: 2028-09-02 Certi�cate ID: IGCCB Preferred Provider 09rtfdp0hl

Docusign Envelope ID: 153C6C5E-F9AB-41D6-95A8-37CD53AA61DE

State of Arizona Board of Behavioral Health Examiners

Be it Known That

Having Exhibited to the Board of Behavioral Health Examiners satisfactory evidence of having met requirements to practice as prescribed by law, is hereby licensed as a

The Arizona Board of Behavioral Health Examiners hereby grants this

License Number:

Under its seal and signatures, Issue Date:

Expiration Date:

Board Chair: Executive Director:

James Bush

Licensed Professional Counselor (LPC)

LPC-21869

03/01/2023 02/28/2027

Docusign Envelope ID: 153C6C5E-F9AB-41D6-95A8-37CD53AA61DE