Certified Telehealth Practitioner

Certified Telehealth Practitioner (CTP)

Standard or Licensed Professionals in Private Practice
The online application process asks you to provide contact information and respond to questions necessary to assess your eligibility for certification as it relates to your personal and professional background and agreement to follow NCBBHP policies and procedures.

Before submitting this application, you must meet these requirements:
- hold an active, recognized behavioral health license or certification,
- completed 18 hours of telehealth specific training, and
- completed five (5) 30-minute telehealth sessions and have participated in follow-up supervision.
This application captures early information used to create a full application. Your current or former supervisor will submit documentation verifying they observed and debriefed at least five (5) 30-minute telehealth sessions.

After these requirements are approved by the Board, you may register for the CTP exam. The CTP credential is awarded after passing the exam.

Your Information
1. Title*
2. First Name*
As shown on your government issued Identification.
2a. Preferred Name*
If you go by a name other than what is on your government issued Identification.
3. Middle Name*
As shown on your government issued Identification.
4. Last Name*
As shown on your government issued Identification.
5. Suffix*
6. Last 4 of SSN*
7. Email Address (personal)*
example@example.com
8. Date of Birth*

MonthDayYear
Date
9. Gender*
10. Race*
11. Ethnicity*

Mailing Address & Employment Information
12. Mailing Address (personal)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
13. Phone Number (personal)*

Area CodePhone Number
14. Current Employer Name*
15. Current Employer Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
16. Employer Phone Number*

Area CodePhone Number
17. Employer Website

Criminal Background
18. Have you ever been convicted, plead no contest, or had an adjudication of guilt withheld for any crime which is a felony or 1st degree misdemeanor?*

Yes (If yes, the Board will contact you for additional information.)No
19. I understand that the Board will not conduct a criminal history check as part of the application process and my certification does not waive any employment related criminal history requirements.*

Yes
20. I understand that if I am found guilty of a first-degree misdemeanor, any felony, or otherwise deemed ineligible to work with the behavioral health population, my credential will be placed in summary suspension status pending the outcome of any necessary investigation by the Board into my conduct.*

Yes
21. I understand that the Board's Code of Ethical and Professional Conduct is posted on the Board's website and it is my responsibility to download, read, understand, and comply with the Code as well as the published Disciplinary Procedures.*

Yes

22. Current Credentials #1

Applicants must hold an active behavioral health license or certification at the time of application. Please enter the requested information for your current behavioral health credentials. You may add up to three (3) credentials.
22a. Credential Name*
22b. Credential Acronym*
22b. Issue Date*

MonthDayYear
22c. Expiration Date*

MonthDayYear
22d. Issuing Authority*
22d. Issuing Authority Website*
22e. Add a Second Credential Entry?*

YesNo
22f. Please upload a copy of your current license or certification.*

Cancelof

23. Add another credential #2
23a. Credential Name
23b. Credential Acronym
23c. Issue Date

MonthDayYear
23d. Expiration Date

MonthDayYear
23e. Issuing Authority
23f. Issuing Authority Website
23g. Add a Third Credential Entry?

YesNo
23h. Upload a copy of your current license or certification.

Cancelof

24. Add another credentials #3
24a. Credential Name
24b. Credential Acronym
24c. Issue Date

MonthDayYear
24d. Expiration Date

MonthDayYear
24e. Issuing Authority
24f. Issuing Authority Website
24g. Upload a copy of your current license or certification.

Cancelof

Formal Education

Your current licensure or certification carries an existing approval of your formal education for credentialing purposes. The Board will not conduct a second official verification of formal education; however, please enter the information about your highest level of education completed.
25. Name of School*
26. City/State*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
27. Formal Education Level*
28. Program of Study/Major*
29. Month and Year of Graduation*

MonthDayYear
Date

What type of application are you applying for?

Standard ApplicationLicensed Professional in Private Practice

Supervised Work Experience
Standard applicants must deliver five (5) thirty-minute telehealth sessions and participate in follow-up supervision. Eligible experience occurred in the five (5) years before application.

In this section, identify each supervisor who will be responsible for documenting the supervised work experience requirement. Then, download and provide a copy of the CTP - Supervised Work Experience Verification Form form to each identified supervisor.

If you would like to share this form, you can copy this link: https://behavioralhealthprofessional.com/wp-content/uploads/2024/03/Feb-2024-CTP-Supervised-Work-Experience-Form.pdf

Supervisors will complete the form and submit it directly to the Board for review. The Board will not accept documentation submitted by the applicant.
Upload the completed form here

Cancelof

Supervised Work Experience
Licensed Professional applicants must deliver five (5) thirty-minute telehealth sessions and participate in follow-up supervision. Eligible experience occurred in the five (5) years before application.

Applicants must complete and document delivery of a minimum of 10 thirty-minute telehealth sessions. Eligible telehealth sessions occurred in the 5 years before application.

Download and complete the CTP - Work Experience Form for Independent Licensed Professional.

If you would like to share this form you can copy this link:
https://behavioralhealthprofessional.com/wp-content/uploads/2024/03/Feb-2024-CTP-Training-Verification.pdf
Upload the completed form here

Cancelof

30. Add information about your eligible current or former supervisors
30a. Supervisor Name*
30b. Supervisor Contact Phone Number*

Area CodePhone Number
30c. Supervisor Email Address*
example@example.com
30d. Supervisor Employer*
30e. Supervisor Position Title*
30f. Add another eligible current or former supervisor*

YesNo

31. Add an additional eligible current or former supervisor
31a. Supervisor Name #2
31b. Supervisor Contact Phone Number

Area CodePhone Number
31c. Supervisor Email Address
example@example.com
31d. Supervisor Employer
31e. Supervisor Position Title

Content Specific Training
Applicants must complete 18 hours of training specific to telehealth. Training hours are allocated across performance domains. Eligible training was completed in the 5 years before application.

Applicants are responsible for providing training documentation to the Board in a clear and organized manner.
1. Download the CTP Training Verification Form from the Board's website.
2. Complete the form by entering requested information for each training event submitted for certification application purposes.
3. Collect training documentation, assemble documents in the same order as listed on the CTP Training Verification Form, create an electronic file of training documentation.
4. Upload the completed CTP Training Verification Form and the training documentation below.
32a. Select the “Choose File” button to upload your electronic Training Verification Form file.*

File types accepted: doc, docx, pdf, txt, wpd, xls, jpg, png (20 mb)
Cancelof
32b. Supporting documentation

File types accepted: doc, docx, pdf, txt, wpd, xls, jpg, png (20 mb)
Cancelof

Attestations
33. I give my permission to the Board and its staff to investigate my personal and professional background as it relates to this application for professional certification, to include all provided information, statements of understanding, agreements, and associated supporting documents used to determine and verify my eligibility for certification.*

Yes
34. I consent to the release of the information contained in my application, to include all supporting documentation and any other pertinent source of information collected by or submitted to the Board in relation to my application to its officers, staff, members of the Board of Directors, and members of Board advisory councils and review committees.*

Yes
35. I consent to the release of the information contained in my application, to include all supporting documentation and any other pertinent source of information collected by or submitted to the Board in relation to my application to its officers, staff, members of the Board of Directors, and members of Board advisory councils and review committees.*

Yes
36. I understand that this application, including all supporting documentation, must be approved by the Board in its entirety before I will be approved to register for and take any required examinations.*

Yes
37. I understand that my credential will be issued after I earn a passing score on any required examinations.*

Yes
38. I understand that I am required to earn the credential within 12 months of application. If I fail to earn the credential in the 12-month period, I may request the option to pay a continuation fee to keep my application active.*

Yes
39. I understand that all Board fees are non-transferable and non-refundable.*

Yes
40. I believe that I am qualified for the level of certification for which I am applying, have submitted correct information in my electronic application, have sought supporting documentation from required sources, and expect to sit for the required examination(s) and hold the credential I am seeking within 12 months or less of application.*

Yes
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Certified Telehealth Practitioner (CTP)

Your Information

Mailing Address & Employment Information

Criminal Background

22. Current Credentials #1

23. Add another credential #2

24. Add another credentials #3

Formal Education

Supervised Work Experience

Supervised Work Experience

30. Add information about your eligible current or former supervisors

31. Add an additional eligible current or former supervisor

Content Specific Training

Attestations