Certified Telehealth Practitioner (CTP) Application

Certified Telehealth Practitioner (CTP)

Standard or Licensed Professionals in Private Practice
The online application collects your contact information and responses to assess your eligibility for certification, including your background and agreement to follow NCBBHP policies.

Before applying, you must meet the following requirements:
- Hold an active, recognized behavioral health license or certification.
- Complete 18 hours of telehealth-specific training.
- Conduct five (5) 30-minute telehealth sessions with follow-up supervision.
This application gathers initial details to begin the certification process. Your supervisor will verify that they observed and debriefed at least five telehealth sessions.

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

Your Personal Information
Title*
First Name*
As shown on your government issued Identification.
Preferred Name*
If you go by a name other than what is on your government issued Identification.
Middle Name*
As shown on your government issued Identification.
Last Name*
As shown on your government issued Identification.
Suffix*
Date of Birth*

MonthDayYear
Date
Last 4 of SSN*
Email Address (personal)*
example@example.com
Gender*
Race*
Ethnicity*

Mailing Address & Employment Information
Mailing Address (personal)*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (personal)*

Area CodePhone Number
Current Employer Name*
Current Employer Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer Phone Number*

Area CodePhone Number
Employer Website

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

Yes (If yes, the Board will contact you for additional information.)No
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
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
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

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.
Credential Name*
Credential Acronym*
Issue Date*

MonthDayYear
Expiration Date*

MonthDayYear
Issuing Authority*
Issuing Authority Website*
Add a Second Credential Entry?*

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

Cancelof

Add another credential #2
Credential Name
Credential Acronym
Issue Date

MonthDayYear
Expiration Date

MonthDayYear
Issuing Authority
Issuing Authority Website
Add a Third Credential Entry?

YesNo
Upload a copy of your current license or certification.

Cancelof

Add another credentials #3
Credential Name
Credential Acronym
Issue Date

MonthDayYear
Expiration Date

MonthDayYear
Issuing Authority
Issuing Authority Website
Upload a copy of your current license or certification.

Cancelof

Formal Education

Your current licensure or certification already approves 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.
Name of School*
City/State*

Street Address

Street Address Line 2

CityState

Zip Code
Formal Education Level*
Program of Study/Major*
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

Add information about your eligible current or former supervisors
Supervisor Name*
Supervisor Contact Phone Number*

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

YesNo

Add an additional eligible current or former supervisor
Supervisor Name #2
Supervisor Contact Phone Number

Area CodePhone Number
Supervisor Email Address
example@example.com
Supervisor Employer
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.
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
Supporting documentation

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

Attestations
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
I consent to the release of the information contained in my application, including 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
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
I understand that my credential will be issued after I earn a passing score on any required examinations.*

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

Yes
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
Electronic Signature*

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Certified Telehealth Practitioner - Application FeeApplication
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Certified Telehealth Practitioner (CTP)

Your Personal Information

Mailing Address & Employment Information

Criminal Background

Current Credentials #1

Add another credential #2

Add another credentials #3

Formal Education

Supervised Work Experience

Supervised Work Experience

Add information about your eligible current or former supervisors

Add an additional eligible current or former supervisor

Content Specific Training

Attestations