Ohio Gambling Treatment Fellowship Program Application

Introduction

You will need the following to complete the application:

Resume
100 word professional bio
Two professional references
500 word essay

Thank you for applying to the Ohio Gambling Treatment Fellowship Program (The Fellowship). The goals of the program are to prepare clinicians in providing gambling treatment services, aiding private practitioners and community agencies in improving gambling treatment services, professional development and strengthening Ohio’s workforce. This includes skills such as the ability to provide clinical treatment in person, telephonically and virtually, to serve as a trainer on topics related to gambling treatment and to serve as a general resource regionally and at the state level on gambling treatment.

The Fellowship is comprised of training, clinical consultation, case conceptualization and professional development. The program concludes with Fellows providing an oral case presentation. Fellows will be asked to bring ideas of potential cases to the Orientation on October 23, 2023 for discussion. Cases for the end-of-year presentations will be selected and confirmed by each Fellow and the Program Facilitator by the third meeting (Dec. 11, 2023).

Please submit the application in full by Monday, September 11th 2023. Applications submitted after Monday, September 11th 2023 may not be considered.

For any questions regarding this application or The Fellowship program, please contact Fellowship@PGNOhio.org.

Program Entry Requirements

● 30 hours of gambling-specific education
● Minimum licensure: must hold an active clinical license through the CSWMFT or OCDP Board*
● Minimum Competency: must hold a GAMB Endorsement or Preliminary (GAMBp) through the OCDP Board and/or claim competency in Gambling Disorder through CSWMFT Board
o CSWMFT Competency deemed as a minimum of 30 hours of gambling specific education
● Applicant must be currently practicing or under supervision in the state of Ohio
● Applicant must have an active Gambling Disorder caseload
● Independent licensure preferred or in process of obtaining

*CDCA, SWA, CT and prevention credentials do not qualify as active clinical licenses

Expectations of the Program

● Mandatory attendance at all Fellowship meetings and trainings
● Completion of a one-on-one mid-program progress call with the Fellowship Facilitator.
● Successful completion of an oral presentation at the conclusion of the program

Stipend

Fellows will receive a stipend of $2,000.00 to cover programmatic expenses such as travel and registration for mandatory events.

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Program Calendar of Important Dates

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* 1. Application Information & Contact Information

Applicant Name as licensed (first, middle and last):

Current Home Address:

Work Address:

Home Phone:

Work Phone:

Mobile Phone:

Fax:

Email:

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* 2. Preferred Mailing Address:

Home

Work

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* 3. Licensure Status

License:

Expiration Date:

License:

Expiration Date:

License:

Expiration Date:

Clinical Supervisor (if applicable):

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* 4. Resume

Attach a copy of your most current resume.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 5. 100 Word Professional Bio
(essay format)

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* 6. References

Two professional references are required

A) Relationship to Applicant:

Name & Credential(s):

Organization:

Phone:

Email:

B) Relationship to Applicant:

Name & Credential(s):

Organization:

Phone:

Email:

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* 7. Essay

In no more than 500 words, please describe your current exposure to Gambling Disorder treatment (ex: caseload, supervision of or diagnostic assessments performed) and how you will utilize the skills and knowledge gained through this program to advance the gambling treatment field in Ohio.

Please upload the essay as a separate document (here) or type into the next box.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 8. Type essay (here) if not attached as a document.

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* 9. Confirmation of Program Dates

Completion of this section by the applicant and supervisor provides verification and approval of Fellowship Program requirements, including dates of mandatory meeting and trainings.

I have received all program related dates, and am able to attend/perform all necessary events/requirements.

Name of Applicant:

Date:

Name of Supervisor:

Date:

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* 10. Have you ever had a professional license/certificate reprimanded, suspended, revoked, surrendered or in any other way sanctioned? (If yes, please attach a written explanation in the next section)

Yes

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* 11. If you selected YES to ever having your professional license/certificate reprimanded, suspended, revoked, surrendered or in any other way sanctioned, please attach a written explanation.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 12. Do you currently live or work at least 51% of the time in Ohio?

Yes

Ohio Gambling Treatment Fellowship Program Application

Introduction

Question Title

Program Calendar of Important Dates

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* 1. Application Information & Contact Information

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* 2. Preferred Mailing Address:

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* 3. Licensure Status

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* 4. Resume

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* 5. 100 Word Professional Bio(essay format)

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* 6. ReferencesTwo professional references are required

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* 8. Type essay (here) if not attached as a document.

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* 10. Have you ever had a professional license/certificate reprimanded, suspended, revoked, surrendered or in any other way sanctioned? (If yes, please attach a written explanation in the next section)

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* 11. If you selected YES to ever having your professional license/certificate reprimanded, suspended, revoked, surrendered or in any other way sanctioned, please attach a written explanation.

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* 12. Do you currently live or work at least 51% of the time in Ohio?

* 5. 100 Word Professional Bio
(essay format)

* 6. References

Two professional references are required