Counselling Referral List Application Page 2
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1
2COUNSELING REFERRAL LIST FOR
CHILDREN AND FAMILIES
Declaration
I declare under penalty of perjury under the laws of the State of California that the statements
below are true and correct:
●
I am licensed in the State of California in one of the following areas: LCSW, MFT, Clinical
Psychologist or board certified Psychiatrist; and have attached a copy of my clinical
license.
●
I have a clinical license in good standing that permits me to provide counseling services
to children and/or families.
●
I will notify the list administrator within two weeks of my license being revoked or
suspended.
●
I am covered by malpractice insurance and have attached a copy of my policy.
●
I have attached my current resume.
●
I have a minimum of 3 years of experience working with families involved in custody
disputes of which at least one year is post-license.
●
I have a minimum of 7 hours of continuing education training pertaining to families
involved in child custody disputes and have attached my attendance certificates.
●
I understand that I can be removed from this list at any time upon written notice from the
list administrator for any reason including but not limited to:
a)
failure to maintain my license in good standing;
b)
failure to inform the list administrator of the revocation or suspension of my license in
a timely fashion;
c)
continued refusal to accept court referrals.
The decision of the committee shall be final and not subject to further review.
In
reviewing complaints, the members of the committee are persons performing quasi-
judicial functions, and presiding at quasi-judicial proceedings within the meaning of
Evidence Code §703.5. The records and information in the possession of the committee
regarding therapists is official information acquired in confidence by public employees in
the course of their duties, and not open, or officially disclosed to the public within the
meaning of both subdivisions (b)(1) and (b)(2) of Evidence Code §1040.
●
I will not use my inclusion on this list in any advertising.
______________________________
_____________________
(Signature)
(Date)
Rev. 7/12
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