DHHS91073 Form 6 - Experience and Education Form.docx
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- Solicitation number
- DHHS91073
- Issued by
- Utah
About this file
This document is an Experience and Education Form related to a contract opportunity with the Utah Department of Health and Human Services (DHHS) to provide various psychological evaluation and consultation services. The form outlines the specific experience and education requirements for providers to qualify for different service categories, including DSPD Eligibility Evaluation, Neuropsychological Evaluation, Psychosexual Evaluation, DSPD Forensic Evaluation, DSPD Consultation, Adult Mental Health Forensic Evaluations, and Juvenile Mental Health Forensic Evaluations. The required experience ranges from 1 to 3 years, and the education requirements include a PhD, PsyD, MD, DO, or LCSW degree. Providers must meet specific criteria related to accredited programs, postdoctoral fellowships, and forensic evaluation experience to qualify for certain service categories.
The related state and local contract opportunity is for the DHHS to procure HIV-related prescription drugs and services from HIV Prevention, Treatment and Care Program providers. The contract has no further details provided, such as estimated value, response dates, award dates, or contract term.
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DHHS91073 Form 6 - Experience & Education Form
Name of Applicant: ___________________________
EXPERIENCE
| Type |
| Requirement |
| Please describe below your experience for each type of service you are applying for. Please include employer name, dates of employment and summary of duties satisfying this requirement. If you do not meet the requirement, please state so. |
| General Experience: all DSPD Evaluation codes |
| One year of professional experience working directly with people with ID.RC and/or with Acquired Brain Injury (ABI), depending on the diagnosis of the Person. |
| General Experience: all DSPD Evaluation codes and Eligibility Determinations (APL) |
| At least one year of experience conducting psychological evaluations with Persons with ID.RC and/or ABI, depending on the diagnosis of the Person. |
| Neuropsychological Evaluation (APN) |
| At least one year of experience in conducting neuropsychological evaluations. |
EXPERIENCE
| Type |
| Requirement |
| Please describe below your experience for each type of service you are applying for. Please include employer name, dates of employment and summary of duties satisfying this requirement. If you do not meet the requirement, please state so. |
Psychosexual Evaluation (APS) At least one year of experience in conducting psychosexual evaluations.
DSPD Forensic Evaluation (APC)
1. If the evaluator has a PhD or PsyD degree in clinical or counseling psychology, the evaluator must have two years of experience in providing psychological or neuropsychological assessment as a licensed psychologist, or have comparable training experience; and have at least 2000 hours of Forensic Evaluation experience.
2. If the evaluator has a Psychiatry MD or DO degree, then the evaluator must have board eligibility or certification in forensic psychiatry; and have at least 2000 hours of Forensic Evaluation experience.
Evaluators who do not meet the requirements in 1 or 2 above will be supervised initially by a forensic evaluator designated by DHHS. This supervision will last a minimum of one year and may be extended by DHHS.
EXPERIENCE
| Type |
| Requirement |
| Please describe below your experience for each type of service you are applying for. Please include employer name, dates of employment and summary of duties satisfying this requirement. If you do not meet the requirement, please state so. |
| DSPD Forensic Evaluation (APD) |
| 1. At least one year of experience diagnosing ID.RC; and |
2. At least one year of experience in conducting forensic evaluations.
Evaluators who do not meet the requirements in 1 and 2 above may seek approval to provide the service by arranging to be supervised until they have the required years of experience.
DSPD
CONSULTATION
(APX)
1. Have at least three years’ of professional experience working directly with people with ID.RC and/or with Acquired Brain Injury (ABI), depending on the diagnosis of the Person; and
2. Have at least one year of experience conducting psychological evaluations with Persons with ID.RC and/or ABI, depending on the diagnosis of the Person.
EXPERIENCE
| Type |
| Requirement |
| Please describe below your experience for each type of service you are applying for. Please include employer name, dates of employment and summary of duties satisfying this requirement. If you do not meet the requirement, please state so. |
Adult Mental Health Forensic Evaluations
(FOR)
1. If the evaluator has a PhD or PsyD degree in clinical or counseling psychology, the evaluator must have two years of experience in providing psychological or neuropsychological assessment as a licensed psychologist, or have comparable training experience; and have at least 2000 hours of Forensic Evaluation experience.
2. If the evaluator has a Psychiatry MD or DO degree, then the evaluator must have board eligibility or certification in forensic psychiatry; and have at least 2000 hours of Forensic Evaluation experience.
3. If the evaluator is an LCSW, the evaluator must have completed 2000 hours of Forensic Evaluation experience. Individuals not meeting this requirement must participate in a probationary period of 2000 hours, be supervised by another forensic evaluator certified by DHHS, and ensure that all forensic evaluations are co-signed by a forensic evaluator certified by DHHS.
Evaluators who do not meet the requirements in 1 or 2 above will be supervised initially by a forensic evaluator designated by DHHS. This supervision will last a minimum of one year and may be extended by DHHS.
EXPERIENCE
| Type |
| Requirement |
| Please describe below your experience for each type of service you are applying for. Please include employer name, dates of employment and summary of duties satisfying this requirement. If you do not meet the requirement, please state so. |
Juvenile Mental Health Forensic Evaluations
(JFE)
1. If the evaluator has a PhD or PsyD degree in clinical or counseling psychology, the evaluator must have two years of experience in providing psychological or neuropsychological assessment as a licensed psychologist, or have comparable training experience; and have at least 2000 hours of Forensic Evaluation experience.
2. If the evaluator has a Psychiatry MD or DO degree, then the evaluator must have board eligibility or certification in forensic psychiatry; and have at least 2000 hours of Forensic Evaluation experience
Evaluators who do not meet the requirements in 1 or 2 above will be supervised initially by a forensic evaluator designated by DHHS. This supervision will last a minimum of one year and may be extended by DHHS.
EDUCATION
| Type |
| Requirement |
| Please describe below your education for each type of service you are applying for. Please include your degree, school & year and/or description of internship or work experience |
DSPD Forensic Evaluation (APC)
1. PhD or PsyD degree in clinical or counseling psychology.
a) The doctoral program in which the evaluator obtained their degree must be accredited by the American Psychological Association.
b) Official school transcripts must verify completion of doctorate course(s) of study and graduation.
c) The evaluator must have successfully completed a postdoctoral fellowship in forensic psychology recognized as meeting experience waiver requirements by the American Board of Forensic Psychology.
OR
2. Psychiatry with a MD or DO degree from a school accredited by the Council for Graduate Medical Education and verifiable by school transcripts.
DSPD Forensic Evaluation (APD), Eligibility Determinations
(APL),
Neuropsychological Evaluation (APN), Psychosexual Evaluation (APS), DSPD Consultation
(APX)
Doctorate in Psychology or Psychiatry from an accredited college or university.
EDUCATION
| Type |
| Requirement |
| Please describe below your education for each type of service you are applying for. Please include your degree, school & year and/or description of internship or work experience |
Adult Mental Health Forensic Evaluations
(FOR)
1. PhD or PsyD degree in clinical or counseling psychology.
a) The doctoral program in which the evaluator obtained their degree must be accredited by the American Psychological Association.
b) Official school transcripts must verify completion of doctorate course(s) of study and graduation.
c) The evaluator must have successfully completed a postdoctoral fellowship in forensic psychology recognized as meeting experience waiver requirements by the American Board of Forensic Psychology.
OR
2. Psychiatry with a MD or DO degree from a school accredited by the Council for Graduate Medical Education and verifiable by school transcripts.
3. If the evaluator is a Licensed Clinical Social Worker, the evaluator must have completed master level courses of study and graduation, verifiable by official school transcripts.
Juvenile Mental Health Forensic Evaluations
(JFE)
1. PhD or PsyD degree in clinical or counseling psychology.
a) The doctoral program in which the evaluator obtained their degree must be accredited by the American Psychological Association.
b) Official school transcripts must verify completion of doctorate course(s) of study and graduation.
c) The evaluator must have successfully completed a postdoctoral fellowship in forensic psychology recognized as meeting experience waiver requirements by the American Board of Forensic Psychology.
2. Psychiatry with a MD or DO degree from a school accredited by the Council for Graduate Medical Education and verifiable by school transcripts.
Check the box next to each service that the person named on page 1 is applying to provide.
| DSPD Eligibility Evaluation and Psychological Services |
| Non- |
Medicaid Service Code
| Psychological Evaluations for DHHS/DSPD Eligibility Determination |
| APL |
| Special Need Evaluation - Neuropsychological |
| APN |
| Special Need Evaluation - Psychosexual |
| APS |
| Forensic Evaluation Services |
| Non- |
Medicaid Service Code
| Psychological Evaluation for, or Restoration Evaluation of, Competency to Stand Trial |
| APC |
| Psychological Evaluation to Determination Exception to Death Penalty |
| APD |
| Forensic Evaluation Services - For A Person Without Intellectual Disabilities - Juvenile |
| JFE |
| Forensic Evaluation Services - For A Person Without Intellectual Disabilities - Adult |
| FOR |
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