MA Problem Gambling Specialist (MA PGS) Certificate This is the form for the MA PGS certificate application. "*" indicates required fields Step 1 of 6 – Personal Information 16% Eligibility to apply for the MA Problem Gambling Specialist (MA PGS) certificate requires a master's or doctoral degree with at least 1 year of addiction-related clinically supervised experience, and clinical licensure in Massachusetts. Are you eligible based on the criteria above?* Yes No If you responded “NO” to the question above, you SHOULD NOT complete this form. Please reach out to our team at mtac@hria.org to learn more about a problem gambling certificate for non-master’s mental health professionals.Name* First Last Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone number*Email* Current Employer* Job Title* Work Address (Agency or Private Practice)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If you would like to receive a physical copy of the certificate at no cost, please choose your preferred address below:* Home Address Work Address I don’t want to receive a copy of the certificate What type of certification are you applying for* First time registration Registration renewal Lapsed registration renewal Name of institution and degree earned* Credentials* Please briefly describe addiction-related clinical experience. (100 word count)*Upload (PDF) your resume demonstrating clinical experience.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.Upload (PDF) of 30 CEs credits/hours of M-TAC & PBU gambling specific course that may include live or on-demand courses. External trainings: up to 6 CEs will be considered toward the certification. The remaining 24 CEs need to be earned from M-TAC/PBU courses. External CEs that are presented for consideration need to be accompanied by the Title and Learning Objectives from the course they came from and must be reviewed and approved.* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Upload (PDF) of 15 CEs credits/hours of M-TAC & PBU gambling specific courses that may include live or on-demand courses. External trainings: up to 4.5 CEs will be considered toward the certification. The remaining 10.5 CEs need to be earned from M-TAC/PBU courses. External CEs that are presented for consideration need to be accompanied by the Title and Learning Objectives from the course they came from and must be reviewed and approved.* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. On-going documented supervision regarding gambling specific or addiction disorder cases with a supervisor is necessary for this certification. This requirement is not necessary if you currently work as a clinical supervisor or are a licensed, independent practitioner in private practice. Please select one statement below:Are you a clinical supervisor?* Yes No Are you an independent practitioner in a private practice?* Yes No Supervision Requirement for both first-time applicants and renewals. This requirement is not necessary if you currently work as a clinical supervisor or an independent practitioner in private practice. Please provide a letter from your supervisor stating that you receive regular clinical supervision and that problem gambling issues will be discussed as they arise with clients. If you are not currently receiving clinical supervision on problem gambling treatment, you still need to submit a letter stating that you receive supervision on other addiction cases.*Accepted file types: pdf, doc, docx, Max. file size: 10 MB.The letter must contain: A description of the applicant’s direct contact with supervision regarding gambling disorder and/or addiction cases. (Group or individual supervision is allowed, but time spent in staff meetings or administrative meetings is not.) A description of the supervised work position and work setting/program during the clinical supervision. The supervisor’s signature and/or sign-off on the supervision. The supervisor’s professional qualifications Please upload a letter from your place of employment certifying your position or a copy of your independent license showing you are in good standing*Accepted file types: pdf, doc, docx, Max. file size: 10 MB. I agree to these ethical codes below:* I agree to the code of conduct listed below I will support all personal and professional efforts toward a primary goal of recovery for myself, the client and their family. I will be and remain committed to the highest quality therapeutic care for those who seek my professional services. I will contribute myself and my work to the best interest of my client and their needs. I will preserve an objective, professional relationship with the client at all times and use my clinical supervision resources if this relationship falls out of balance. I will follow the laws and regulations pertaining to the confidentiality of all records, material and knowledge concerning the client and equal service to all clients. I will adhere to all policies and management functions within my institution, and advance said policies and functions with my clients. I will continue to assess my own personal strengths, limitations, biases and effectiveness regularly and understand my responsibility for professional growth through further education and training. I will manage my own conduct in all areas, including use of gambling, alcohol and other drugs and other addictive behaviors. I will only state any personal capabilities or professional qualifications actually gained. I will not impose my own view on gambling or any issues related to gambling on my clients. Disciplinary HistoryHas any disciplinary action been taken against you by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Are you the subject of pending disciplinary action by a licensing/certification board located in the United States or any country or foreign jurisdiction?* Yes No Have you voluntarily surrendered or resigned a professional license (does not include non- renewal or expired licenses) to a licensing/certification board in the United States or any country or foreign jurisdiction?* Yes No Have you ever been denied a professional license in the United States or any country or foreign jurisdiction?* Yes No Please explain why you answered "yes" to any of the above questions:*CONSENT TO RELEASE OF INFORMATION* I consent to the information release below By checking the box above and providing your digital signature, you are consenting to the following: I give permission to HRiA to request information from my present and past employers, and any institution or agency with which I am or have been associated. Information may be obtained from any individual (from my associations shared in this document), to determine my professional competence and accomplishments. I consent to HRiA inspecting any documents or records necessary to determine my “acceptable standard” to receive the MA PGS certificate. I hereby release from any liability all representatives of HRiA and all individuals and organizations who provide information to HRiA while acting in good faith, to determine my credentials. I am aware that any false or misleading information deliberately given will be considered a serious matter, and will be dealt with accordingly. I understand that this release expires one year from the signature date. Would you like to receive treatment referrals for your agency or private practice from M-TAC and the MA Problem Gambling Helpline?* Yes No Please provide the following referral information* Contact information for problem gambling treatment (name of agency/private practice, website if applicable, email address, phone number) Other important referral information Many clients feel comfortable seeking help with professionals who share their own gender identities. Please share your gender identity Many clients feel comfortable seeking help with professionals who share their own race/ethnic identities. Please share your race/ethnic identity(ies) What language(s) do you speak?* Please list payment options: (i.e. insurance taken, sliding scale, set fee, etc.)* Days/hours of the week open:*I currently maintain professional liability insurance Yes No Through the following insurer: Submit a copy of liability insuranceAccepted file types: pdf, doc, docx, Max. file size: 10 MB.Do you also treat family members of clients who experience problem gambling?* Yes No Any other specialties? If so please list Digital Signature*By signing your name in the box below, it is the same as a wet signature on a legal document. I certify that all answers above are truthful to the best of my knowledge. Date MM slash DD slash YYYY New Registration Price: Registration Renewal Price: Lapsed Registration Renewal Price: Credit Card EmailThis field is for validation purposes and should be left unchanged.