Eligibility Determination for NC-SNAP Training

24-Hour Crisis Care & Service Enrollment – 877.685.2415 Business & Administrative Matters - 866.998.2597 TrilliumHealthResources.org

Name:

Agency:

Degree: Discipline (what your degree is in):

Institution (College/University) you received your degree from:

Date you received your degree:

Professional License or Certification Type and Number (if applicable):

Current Professional Credential Status: QP (Qualified Professional) in: I/DD MH SUAP (Associate Professional) in: I/DD MH MH

If AP, name and qualifications/credentials of current clinical supervisor. Is your supervisor privileged to perform the NCSNAP?

What is your current position?

What services will you be providing?

Age and disability of population to be served in current position:

Number of years of supervised work experience providing I/DD habilitative services:

Please provide a brief synopsis of your work experience with people with I/DD. Include number of years worked, agency name, and type of work/position held.

NC-SNAP Examiner Training Registration Form

Training Date Requested:

Training Location:

Agency Requesting Training:

Referring MCO:

MCO’s Training Coordinator:

Note: The data on this form is pasted into a database and then used to generate class sign-in sheets, examiner certification cards and mailing labels. Please type all

information as it should appear on a mailing label.

Name (Please Do Not use all caps)

Job Title, Agency Name (please list job title, agency name)

Phone Please format as

(999) 999-9999

Business Address

Street City, State, Zip

Please note that NC-SNAP examiner certification is only available to persons who will be responsible for completing or reviewing NC-SNAP

assessments as part of their job responsibilities and who meet minimum qualifications as established by the MCO.

As such, NC-SNAP examiner certification is available by MCO referral only (i.e., provider agencies should email training requests to the

MCO’s NC-SNAP training coordinator for approval (PLEASE DO NOT FAX REGISTRATION FORMS).

MCO NC-SNAP training coordinators should forward approved registration requests to the preferred training site after careful review

of the applicants’ qualifications.

Jennifer Coston