GMHCN CPS Recertification Training Application Form

GMHCN CPS Recertification Training Application Form
Welcome to the Georgia Mental Health Consumer Network CPS Recertification Training Registration and Payment Form.

This form is to be used by CPS-MH or Agency administrators who employ CPS-MH that have not completed any Continuing Education requirments in over 2 years.

Any CPS-MH who has not completed continuing education are not eligile to bill Medicaid and risk their agency having to pay Medicaid back for any notes the CPS has signed off on while out of compliance.

The total cost of the recertification training is $625 per person. A $50 deposit is required for each person and the additional amount of $575 is due at least 2 weeks before the training.

If payment arrangements need to be made, please reach out to Heather James at hjames@gmhcn.org.

Please note that if payment arrangements are being made, certificates will not be issued until receipt of final payment.

Please ensure that each section is completed in its entirety and is accurate. CPS Certificates will be mailed to the address listed in the participant field. If an employer's address is being used instead of the participant's address, then it is the responsibility of the employer to distribute the CPS Certificate to the appropriate person.
Contact Person

Please provide information for the point of contact
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.*

0/100
Please indicate who you are registering*
Participant Information

Please provide accurate information for all individuals participating in the training. Please note that CPS Certificates will be mailed to the address provided in this section.

Participant 1
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100
Phone Number
E-mail
example@example.com

Participant 2
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 3
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 4
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 5
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 6
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 7
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 8
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 9
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Participant 10
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
In 100 word or less, please explain how you plan to maintain your CPS certification going forward.

0/100

Payment Information
Billing information*

Billing information is the same as contact personBilling information is different from the contact person
Full Name*

First NameLast Name
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My Products*
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CPS Recertification Training DepositA $50 deposit must be made to hold your seat in the CPS Recertification Training
$50.00 Quantity

Total

$0.00
Should be Empty:

GMHCN CPS Recertification Training Application Form

Contact Person

Participant Information

Payment Information