Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Updated 3/31/2014 Disclosure for: (See attached pages)

Transcription

1 Vermont Board of Allied Mental Health Practitioners Licensed Clinical Mental Health Counselor Updated 3/31/2014 Disclosure for: Thomas J. Mott LCMHC, LADC, CT Qualifications and Experience (See attached pages) Information concerning unprofessional conduct for this profession is attached. CLIENT S DISCLOSURE CONFIRMATION My signature acknowledges that I have been given the professional qualifications and experience of Thomas J. Mott, a listing of actions that constitutes unprofessional conduct according to Vermont statutes, and for making a consumer inquiry or filing a complaint with the Office of Professional Regulation. Client Signature Date Practitioner s Signature Date Page 1 of 13

2 FORMAL EDUCATION Dates College of St. Joseph, Rutland, VT 9/2002-5/2007 Master of Science in Clinical Psychology State University of New York, Plattsburgh, NY 9/1975-8/1978 Degree: Bachelor of Liberal Arts, (120 credit hours w/concentrations in Psychology) CREDENTIALS Licensed Clinical Mental Health Counselor, State of Vermont Secretary of State s Office of Professional Regulation (2011 present) Licensed Alcohol and Drug Counselor, Vermont Department of Health (2009 present) Certified in Thanatology: Death, Dying and Bereavement, The Association for Death Education and Counseling, (2014 present) Psychotherapist, State of Vermont roster of non-licensed psychotherapists ( ) PROFESSIONAL ORGANIZATION MEMBERSHIPS Association for Death Education and Counseling TRAINING Undergraduate and graduate courses: Foundations of Addictions, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2005 Intellectual Assessment, 3.00 Cr. College of St. Joseph, Rutland VT. Fall 2005 Developmental Psychology, 3.00 Cr. College of St. Joseph, Rutland,VT Fall 2002 Personality Assessment, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2006 Advanced Abnormal Psychology, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2003 Counseling Techniques, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2005 Page 2 of 13

3 Career Counseling, 3.00 Cr. University of Vermont,. Spring 2009 Family Systems, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2006 Diversity and Professional Relationships, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2004 Research Methods, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2004 Anthropology of Death, 3.00 Cr. Johnson State College, Winooski VT. Summer 2013 Group Counseling, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2007 Advanced Theories of Psychotherapy, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2004 Clinical Practicum I, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2005 Clinical Practicum II, 3.00 Cr. College of St. Joseph, VT. Spring 2006 Ethical and Professional Issues, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2002 Psychopharmacology, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2003 Clinical Internship I, 3.00 Cr. College of St. Joseph, Rutland, VT. Fall 2006 Clinical Internship II, 3.00 Cr. College of St. Joseph, Rutland, VT. Spring 2007 Psychological Appraisal, 3.00 Cr. College of St. Joseph, Rutland, VT. Summer 2003 Transformational Learning, 3.00 Cr. College of St. Joseph, Rutland, VT. Summer 2003 Gift of Healing, 3.00 Cr. College of St. Joseph, Rutland, VT. Summer 2005 Workshops Seminars: September 20, 2013 Cause and Effect vs. Systems Thinking: Maternal Deprivation vs. Emotional Fusion Michael Kerr, M.D. Vermont Center for the Family Holiday Inn Express, South 5.25 CEU Page 3 of 13

4 September 11, 2013 Treatment For Women with Co-Occurring Disorders Laurie Markoff, Ph.D., M.D. The New England School of Addiction Studies, School of Best Practices Waterville Valley Resort, Waterville, NH September 11, 2013 Best Practices in the Integration of Mental Health and Substance Abuse Services into Primary Care Alexander Blount, EdD The New England School of Addiction Studies, School of Best Practices Waterville Valley Resort, Waterville, NH September 10, 2013 Ethics & Clinical Supervision David Powell, PhD The New England School of Addiction Studies, School of Best Practices Waterville Valley Resort, Waterville, NH September 9, 2013 Treating Men: Tools for Emotional Fitness David Powell, PhD The New England School of Addiction Studies, School of Best Practices Waterville Valley Resort, Waterville, NH September 8, 2013 DSM Update: Implications for the Addiction Field Lloyd L. Lyter, Ph.D. The New England School of Addiction Studies, School of Best Practices Waterville Valley Resort, Waterville, NH June 8 & 9, July 13 & 27, 2013 Anthropology of Death Virginia Fry, LICSW Johnson State College Winooski, VT 3 credits April 4, 2013 Conquering Pain Institute For Natural Resources Holiday Inn Express So. Page 4 of 13

5 August 20 and 21, 2012 ORAS Criminal Risk Assessment Win Turner, PhD The Vermont Dept. of Health, The Court Administrators Office Montpelier, VT 12 CEU June 18-21, 2012 Medication Assisted Recovery and Buprenorphine Awareness New England School of Addiction Studies Bowdoin College, Brunswick, Maine 11 CEU May 4, 2012 Seeking Safety, Creating Change Trauma and Substance Abuse Interventions Lisa M. Najavits, Ph.D., ABPP Behavioral Health Network of Vermont Capital Plaza Hotel Montpelier, VT April 19, 2012 ADHD Across the Lifespan Jefferson B. Prince, M.D. Doubletree Hotel March 22, 2012 Understanding and Confronting Ethical Challenges Daniel B. Jacobs, Ed.M., M.B.A., Psy.D. Doubletree Hotel Burlington VT January 27, 2012 Life After Loss- Clinical Interventions for Normal and Complicated Grief Robert Zucker, MA, LCSW, FT CMI Education Institute Holiday Inn Express, November 10, 2011 Bridging the Divide Conference The University of Vermont College of Medicine Sheraton Hotel, 7 Continuing education credits Page 5 of 13

6 August 1 & 2, 2011 Integrating Solution Focused Therapy into Your Clinical Work Utilizing Solution Focused Brief Therapy with Children and Families Susan Lee Tohn, MSW, LICSW Counseling Service of Addison County Middlebury, VT 12 Continuing Education Credits May 16, 2011 Understanding the Frontal Lobes: Emotional Regulation, Social Intelligence and Motivation Mark B. Moss, Ph.D. Institute For Brain Potential Holiday Inn, So. April 29, 2011 Prescription and Over the Counter Drug Misuse Mary Pickener, LICSW, LADC State of Vermont Dept. of Health Northwestern Counseling & Support Services St. Albans, VT 1 CEU February10, 2011 Anxiety Disorders in Children and Adolescents: Recognizing & Treating the Emerging Epidemic Paul Foxman, Ph.D. Premier Education Solutions Sheraton Hotel 6.0 Contact hours June 4, 2010 Ethics in Action II, Risk Management, Advanced Ethics & Your Professional Identity David Jobes, Ph.D. HEALTH Education Network, LLC 6.0 hours April 5,2010 You Worry Too Much! Clinical Approaches to Excessive Worry William J. McCann, Psy.D. PESI Doubletree Hotel January 22, 2010 Combating Anger: Best Treatment Techniques for Adolescents and Adults Page 6 of 13

7 Raymond Chip Tafrate, Ph.D. PESI Hilton Hotel 6.25 Credit hours July 3, 2009 May 26, 2009 Dual Diagnosis Treatment: A Map to Recovery Part 2 Marc Bono Psy.D. Brown University Distance Learning Program Williston, VT 10 educational credits June 4, 2009 Track 01: Medical Scholars/Allied Health 2009 National Rural Institute on Alcohol and Drug Abuse University of Wisconsin Stout 2.2 CEU May 8, 2009 March 30, 2009 Dual Diagnosis Treatment: A Map to Recovery Marc Bono Psy.D. Brown University Distance Learning Program Williston, VT 10 Educational credits April 29 & 30, 2009 Witnessing Skills Suzanne Legare Belcher Agency of Human Services Dept. of Children and Families UVM Child Welfare Training Partnership 10.5 hours April 27, 2009 Hepatitis C Workshop Alan Franciscus Hepatitis C Support Project November 17 & 18, 2008 Motivational Interviewing Win Turner, Ph.D., LADC Jody Kamon, Ph.D. Dept. of Children and Families Colchester, VT Page 7 of 13

8 September 26, 2008 Improving Care for Opioid Exposed Newborns Anne Johnston, M.D. Vermont Regional Perinatal Health Project Vermont Children s Hospital 2 Contact hours September 24 & 25, 2008 Vermont Conference on Addictive Disorders Carlo C. DiClemente, Ph.D. ABPP Karen Crowley Vermont Alcohol and Drug Abuse Certification Board 11.5 CEU s September 23, 2008 A Clinician s Perspective William Keithcart, MA, LADC DayOne, Fletcher Allen Health Care September 22, 2008 Collaborative Values Inventory: What Do We Believe about Alcohol and Other Drugs, Services to Children and Families and Dependency Courts? National Center on Substance Abuse and Child Welfare, The Danya Institute Williston, VT 4 Credit hours- Online training September 19, 2008 Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals National Center on Substance Abuse and Child Welfare, The Danya Institute Williston, VT 4 Credit hours- Online training September 15, 2008 Family Group Decision Making and The Family Group Conference Gale Burford & Sarah Gallagher Dept. of Social Work, Child Welfare Training Partnership University of Vermont 2 Credit hours September 12, 2008 Understanding Substance Abuse Treatment: A Guide for Child Welfare Workers National Center on Substance Abuse and Child Welfare, The Danya Institute Williston, VT 4 Credit hours-online training Page 8 of 13

9 September 4, 2008 Co-Occurring Disorders Anthony R. Quintilani, Ph.D., LADC Vermont Addictions Academy 1 Credit hour September 3, 2008 Court Supervision Protocol Judge James Cruscetti Vermont Dept. Of Children and Families 2 Credit hours April 11, 2008 Mandated Reporting Homeland Security and Emergency Management New Hampshire Chapter and the National Association of Social Workers Keene State College, Keene, NH 1 CEU March 21, 2008 HIV Trends and Treatment 2008 Peter DalPra, LADC, LCS New Hampshire Training Institute On Addictive Disorders Concord, NH December 7, 2007 The 12 Core Functions of the Substance Abuse Counselor David Parisi, LICSW, LADC New Hampshire Training Institute On Addictive Disorders Concord, NH June 11 13, 2007 DDAP Dual Diagnosis Aftercare Program: Incorporating Dual Diagnosis Treatment Concepts into Mental Health and Substance Abuse Cognitive Behavioral Treatment What Every Clinician Should Know About Differential Diagnosis for Co-Occurring Disorders The New England School of Addiction Studies Bowdoin College, Brunswick, ME 30 CEU s June 6, 2007 Treating Compulsive Sexual Behaviors Cross Country Education Page 9 of 13

10 6 CEU s June 1, 2007 & May 31, 2007 Using Dialectical Behavior Therapy On The Front Lines: Adaptations of DBT For Clinical Support Staff in Mental Health Programs Charles Swenson, MD & Randy Wolbert, MSW Behavioral Tech, LLC Boston, MA 12.5 credit hours March 8, 2007 Evidence-Based Treatments-Mindfullness-Based Interventions in the Core Co-Occurring Disorders Anthony R. Quintilani, Ph.D., LADC The National Association of Social Worker s Vermont Chapter & Rehabilitative Services Springfield, VT 5 Contact hours March 26, 2007 Ethical Considerations for Licensed Mental Health Professionals Willingham L. Cunningham, Ph.D. Vermont Educational Support Associates, Inc. Rutland, VT 2 Contact hours November 11, 2006 The Mandt System Easter Seals of Vermont and New Hampshire Manchester, NH August 3 & 4, 2006 Substance Abuse 101+ for Mental Health Professionals Providing Co-Occurring Services Anthony R. Quintilani, Ph.D., LADC State of Vermont Dept. of Health, Division of Mental Health Stratton Mountain Resort Stratton, VT 11 CEU s April, May and June Day Training Program In Dialetical Behavior Therapy Mary Buttitta, MS LCMHC Vermont Agency of Human Services, Dept. of Health, Division of Mental Health 3 Page 10 of 13

11 EXPERIENCE IN THE PRACTICE OF PSYCHOTHERAPY Experience in Psychotherapy/Counseling: Azimuth Counseling and Therapeutic Services, Inc. Psychotherapist April 2012 (part time), December 2012 (full time)- present independent practice Psychotherapist September present (part time) Northwestern Counseling & Support Services October 2009 December 2012 Full time Supervised by Oliver Quayle, M.A., Licensed Psychologist Masters Counseling Connections Training Institute/Counseling Connections Clinician Part Time September 2008 September 2010 James Farrell, Licensed Psychologist Masters Lund Family Center Substance Abuse Clinician September 2008 September 2009 Full Time Supervised by Kay Frances Schepp, Ed.D., Licensed Psychologist Doctorate West Central Behavioral Health Clinician July 2007 August 2008 Full Time Supervised by Mark Linnett, LCMHC, LADC Healthcare & Rehabilitative Services Case Manager II/Clinician Intern March 2006 July 2007 Full time Supervised by Jonathan Gilmore, MA SCOPE OF PRACTICE Theoretical orientation: Eclectic- Cognitive/ Behavioral, Solution Focused, Motivational Interviewing Page 11 of 13

12 Area of specialization: Children and adults individually, families and groups, insight oriented, children, adolescence and adult substance abuse Treatment methods: Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Solution Focused Therapy, Motivational Interviewing/ Collaboration with clients to assist in making and implementing plans to assist them in meeting their goals/ Collaboration with other healthcare providers and significant people in the client s life to aid in providing support and accountability. Page 12 of 13

13 Vermont Secretary of State Office of Professional Regulations Board of Allied Mental Health Practitioners Title 26: Professions and Occupations Chapter 65: Clinical Mental Health Counselors Unprofessional conduct (a) Unprofessional conduct means the following conduct and conduct set forth in section 129a of Title 3: (1) using dishonest or misleading advertising; (2) misusing a title in professional activity; (3) conduct which evidences unfitness to practice clinical mental health counseling; (4) engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous five years; (5) harassing, intimidating, or abusing a client; (6) entering into an additional relationship with a client, supervisee, research participant or student that might impair the licensed clinical mental health counselor's objectivity or otherwise interfere with the clinical mental health counselor's professional obligations; (7) independently practicing outside or beyond a clinical mental health counselor's area of training, experience or competence without appropriate supervision. (b) After hearing, and upon a finding of unprofessional conduct, the board may take disciplinary action against a licensed clinical mental health counselor or applicant. (Added 1987, No. 245 (Adj. Sess.), 1; amended 1993, No. 98, 17; 1993, No. 222 (Adj. Sess.), 10; 1997, No. 40, 57; 1997, No. 145 (Adj. Sess.), 53; 2007, No. 29, 45.) For more information regarding Professional Conduct please see Page 13 of 13