DOH Form 670-114 "Agency Affiliated Counselor Employment/Student Verification Form" - Washington

What Is DOH Form 670-114?

This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Washington State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOH Form 670-114 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download DOH Form 670-114 "Agency Affiliated Counselor Employment/Student Verification Form" - Washington

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Agency Affiliated Counselor Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Agency Affiliated Counselor
Employment/Student Verification Form
“Agency affiliated counselor” means a person registered under this chapter who is engaged in counseling and
employed by an agency or is a student intern, as defined by the department, who is supervised by agency
staff.
“Agency affiliated counselor” includes juvenile probation counselors who are employees of the juvenile court
under
RCW 13.04.035
and
13.04.040
and juvenile court employees providing functional family therapy,
aggression replacement training, or other evidence-based programs approved by the department of children,
youth, and families.
Type of Agency Affiliated Counselor:
Mark All That Apply:
Employee
Juvenile Probation Counselor
Student Intern
c
c
c
Check One:
New Agency
Update / Change Agency
Additional Agency
c
c
c
Applicants may not provide unsupervised counseling prior to completion of a criminal background check
performed by either the employer or the Department of Health.
Agency affiliated counselors shall notify the department if they are either no longer employed by the agency
identified on their application or are now employed with another agency, or both. See
RCW
18.19.210.
________________________________________________________________________________________
Agency Affiliated Applicant Name and Credential Number (Please Print)
I verify that the above applicant is currently employed or will begin employment with the agency listed below as
required by
WAC
246-810-015.
________________________________________________________________________________________
Agency or Facility Employer Name
________________________________________________________________________________________
Agency or Facility Physical Address
________________________________________________________________________________________
City
State
Zip Code
My Agency is a county, state agency, federally recognized Indian tribe located within Washington State or has
been recognized by the Secretary of Health to be able to employ agency affiliated counselors.
See
WAC 246-810-016
and
WAC
246-810-015. Please see the
approved agency affiliated
list.
_______________________________________________________________________________________
Signature of employer or designated/authorized employee
Date MM/DD/YYYY
Send this completed form to the address above.
DOH 670-114 July 2021
Agency Affiliated Counselor Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Agency Affiliated Counselor
Employment/Student Verification Form
“Agency affiliated counselor” means a person registered under this chapter who is engaged in counseling and
employed by an agency or is a student intern, as defined by the department, who is supervised by agency
staff.
“Agency affiliated counselor” includes juvenile probation counselors who are employees of the juvenile court
under
RCW 13.04.035
and
13.04.040
and juvenile court employees providing functional family therapy,
aggression replacement training, or other evidence-based programs approved by the department of children,
youth, and families.
Type of Agency Affiliated Counselor:
Mark All That Apply:
Employee
Juvenile Probation Counselor
Student Intern
c
c
c
Check One:
New Agency
Update / Change Agency
Additional Agency
c
c
c
Applicants may not provide unsupervised counseling prior to completion of a criminal background check
performed by either the employer or the Department of Health.
Agency affiliated counselors shall notify the department if they are either no longer employed by the agency
identified on their application or are now employed with another agency, or both. See
RCW
18.19.210.
________________________________________________________________________________________
Agency Affiliated Applicant Name and Credential Number (Please Print)
I verify that the above applicant is currently employed or will begin employment with the agency listed below as
required by
WAC
246-810-015.
________________________________________________________________________________________
Agency or Facility Employer Name
________________________________________________________________________________________
Agency or Facility Physical Address
________________________________________________________________________________________
City
State
Zip Code
My Agency is a county, state agency, federally recognized Indian tribe located within Washington State or has
been recognized by the Secretary of Health to be able to employ agency affiliated counselors.
See
WAC 246-810-016
and
WAC
246-810-015. Please see the
approved agency affiliated
list.
_______________________________________________________________________________________
Signature of employer or designated/authorized employee
Date MM/DD/YYYY
Send this completed form to the address above.
DOH 670-114 July 2021