Dear Trainee,

Congratulations on successfully completing Part 1 of the Dr. DeeAnna Merz Nagel Clinical Supervision Series. Your achievement is a reflection of our shared commitment to professional growth, and we are pleased to offer reimbursement for the cost of your training upon completion.

As a program supported by both public and private funding, COBHC adheres to strict compliance guidelines set forth by our funders. These include documentation of participant need, training progression, and responsible use of public funds. To initiate your reimbursement, please complete the required sections and submit all supporting documentation.

If you have any questions regarding this process, please don't hesitate to contact the EC Works Business Services Manager.

Sincerely,
Central Oregon Behavioral Health Council
Your Information

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* 1. Full Legal Name:

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* 2. Mailing Address:

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* 3. Email:

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* 4. Phone:

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* 5. Credentials:

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* 6. Place of Employment:

Funding Guidelines/Training Progression/Contract Requirements
The following steps are required:
  • Complete and submit this Regional Supervision Training Reimbursement Agreement via SurveyMonkey.
  • Complete and upload W9 and ACH forms (downloadable from the Documents and Forms page of the COBHC website).
  • Upload proof of purchase of the Dr. DeeAnna Merz Nagel Clinical Supervision Series Part 1, along with proof of completion within 6 months of the purchase date of the program materials.

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* 7. Please upload the required documents. If uploading each as a separate file, use the additional upload buttons below.
  • W9
  • ACH
  • Proof of purchase of the Dr. DeeAnna Merz Nagel Clinical Supervision Series Part 1
  • Proof of completion of the Dr. DeeAnna Merz Nagel Clinical Supervision Series Part 1

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* 8. Upload additional files here if needed.

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* 9. Upload additional files here if needed.

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* 10. Upload additional files here if needed.

Signature

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* 11. Trainee Signature:

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* 12. Date:

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