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California Infant-Family and Early Childhood
Mental Health Endorsement Application -----Supplemental Request-----

Use this form ONLY if you have already received a previous endorsement from the CA Center and are seeking a change from TMHP to ATMHP or MHS and/or reflective practice or mentor endorsement.

Transdisciplinary or Advanced Mental Health Practioners who are now requesting Mental Health Specialist endorsement must have a masters degree and submit narrative documentation of the higher number of training hours in Domain 1 (knowledge) and Domain 2 (direct service experience supported by reflective practice facilitation. (If you previously submitted the learning narrative and documentation using the MHS criteria, you may use the same documents but edit the endorsement title requested.)

Mental Health Specialists need to meet the MHS criteria, a letter of recommendation stating the category and age group, Masters degree and a professional license or credential from a state regulatory agency.

Reflective Practice Facilitator I or II will need letters of recommendation from whomever trained/mentored you to become a reflective practice facilitator and email verifications from 3 people who have received reflective practice from you.

Reflective Practice Mentor will need the letter of recommendation documenting the reflective practice facilitation training you received from them related to becoming a reflective practice mentor, verify training, submit a video, provide 3 names and email addresses for people who can verify that you provided reflective practice mentoring to them as they become reflective practice facilitators.

I. Demographic Data (Name as you want it to appear on your supplemental endorsement certificate and street address for UPS delivery of the certificate.)

First Name *

Middle Name or Initial

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Preferred Email Address *

Work Phone

Home/Cell Phone

Which county in California do you wish to be listed under for the endorsee post on our website.

I am currently endorsed (category and age group) as a:

Select the supplemental endorsement button if you already hold a:

TMHP 0-3 or TMHP 3-5 and applying for the TMHP, select TMHP 0-5.

ATMHP 0-3 or ATMHP 3-5 and applying for the ATMHP 0-5, select ATMHP 0-5.

TMHP endorsement and are applying only for the Advanced TMHP select ATMHP.

TMHP/ATMHP endorsement and are applying for the MHS, select the MHS.

MHS 0-3 or MHS 3-5 and applying for the MHS 0-5, select MHS 0-5.

TMHP or ATMHP endorsement and adding Reflective Practice Facilitator endorsement, select RPF I.

MHS endorsement adding Reflective Practice Facilitator select RPF II.

TMHP/ATMHP RPF I or MHS/RPF II may select RPMentor.

Transdisciplinary Mental Health Practitioner 0-5 (Currently hold only a 0-3 or 4-5 age group)

Advanced Transdisciplinary Mental Health Practitioner (ATMHP) - Applying for either 0-3 or 3-5

Advanced Transdisciplinary Mental Health Practitioner (ATMHP) - Applying for 0-5

Advanced Transdisciplinary Mental Health Practitioner 0-5 (Currently hold only a 0-3 or 4-5 age group)

Mental Health Specialist 0-5 (Currently hold only a 0-3 or 4-5 age group)

Mental Health Specialist (MHS) (Currently hold a Certificate for TMHP)

Reflective Practice Facilitator I (RPF I)

Reflective Practice Facilitator II (RPF II)

Reflective Practice Mentor (RPM)

California Infant-Family and Early ChildhoodMental Health Endorsement Application -----Supplemental Request-----

California Infant-Family and Early Childhood
Mental Health Endorsement Application -----Supplemental Request-----