PMH-C Extension Application
Please fill out this form to request an extension for PMH-C renewal. Failure to renew will result in the automatic placement of the certification in “Suspended” status and the inability to use the PMH-C credentials. This application for an extension gives you 6 months from the date of expiration to complete 12 CEs. This application and a $75 extension fee must be received before the recertification deadline and the certification expiration date. Please complete this form and make a payment on the link below to apply for an extension. The next certification period expiration date is based on the date of initial certification. Failure to renew the certification a year after the initial certification will require a re-examination. Pay the extension fee using this link: https://postpartum.app.neoncrm.com/np/clients/postpartum/product.jsp?product=138&
Name
*
First Name
Last Name
PSI Number
*
Expiration Date
*
-
Month
-
Day
Year
Date
Track
*
Please Select
Affiliated Professionals
Mental Health/Psychotherapy
Psychopharmacology
Have you paid the extension fee?
*
Please Select
Yes
Not yet
https://postpartum.app.neoncrm.com/np/clients/postpartum/product.jsp?product=138&
Date the payment of extension fee was made?
-
Month
-
Day
Year
Please leave blank if no payment has been made
Submit
Should be Empty: