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Vermont Board of Allied Mental Health Practitioners

Licensed Clinical Mental Health Counselor

Updated February 2015

Disclosure for:

CHRISTINE PAYNE

Qualifications and Experience

(See attached pages)

My signature acknowledges that I have been given a disclosure packet listing the professional qualifications, experience and supervision of my therapist. I have been informed that their practice is governed by the Rules of the Board of Allied Mental Health Practitioners. A copy of these rules or how to lodge a complaint may be obtained from the Board or online at: http://vtprofessionals.org/. A listing of actions that constitutes unprofessional conduct according to Vermont statutes, and for making a consumer inquiry or filing a complaint with the Office of

Professional Regulation.

__________________________________ ___________________

Client Signature Date

___________________________________ ___________________

Practitioner’s Signature Date

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Johnson State College, Johnson, VT

Master of Arts in Counseling, 6/2005 - 5/2008.

University of Vermont, Burlington, VT

Fifth Year Certificate in Education, 1980-1981.

University of Vermont, Burlington, VT

Bachelor of Arts, Sociology. 1976-1980.

CREDENTIALS

Licensed Clinical Mental Health Counselor

State Of Vermont Secretary of State’s Office of Professional Regulation

2/01/2015 – 1/31/2017

Psychotherapist

State of Vermont roster of non-licensed psychotherapists

12/1/2010-11/20/2014

TRAINING

Graduate Courses:

Death, Dying, and Grieving, 3.00 credits. Johnson State College, Summer, 2005.

Counseling Theories, 3.00 credits, Johnson State College, Fall 2005.

Lab Experience I, 3.00 credits, Johnson State College, Fall 2005.

Counseling in Groups, 3.00 credits, Johnson State College, Fall 2005.

Lab Experience II, 3.00 credits, Johnson State College, Spring 2006.

Counseling and Addictive Behaviors, 3.00 credits, Johnson State College, Spring 2006.

Family Counseling, 3.00 credits, Johnson State College, Spring 2006.

Lifespan Development, 3.00 credits, Johnson State College, Spring 2006.

Career Counseling, 3.00 credits, Johnson State College, Summer 2006.

Practicum in Counseling, 3.00 credits, Johnson State College, Summer/Fall 2006.

Legal & Ethical Issues, 3.00 credits, Johnson State College, Fall, 2006.

Psychopharmacology 3.00 credits, Johnson State College, Fall, 2006.

Psychopathology, 3.00 credits, Johnson State College, Spring, 2007.

Social & Cultural Foundations, 3.00 credits, Johnson State College, Spring, 2007.

Evaluation & Measurement, 3.00 credits, Johnson State College, Spring, 2007.

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Research Methods, 3.00 credits, Johnson State College, Summer, 2007.

Internship in Counseling, 9.00 credits, Johnson State College, July 2007- May 2008.

Internship Seminar, 3.00 credits, Johnson State College, Fall 2007, Spring, 2008.

Professional Workshops/Seminars:

March 11, 2014

Personality Disorders in Social Work & Health Care

Gregory W. Lester, PhD.

Held at Holiday Inn,

South Burlington VT 05403

6 CEUs

September 20, 2013

Forces in the Family – Exploring Differentiation: From Sandy Hook to Marital Conflict

Dr. Michael Kerr

Vermont Center for Family Studies

Held at Holiday Inn,

South Burlington VT

5.25 CEUs

September 10, 2010

Working With Personality Disorders: Obsessive, Histrionic and Borderline

David Celani, Ph.D.

Held at Inn at Essex

Essex, VT 05452

October 9-10, 2008

Loving Couples, Loving Children Facilitator Training.

Vermont Family Matters

Held at The Stoweflake, Stowe, VT

August 6, 2008

Understanding and Responding to Sexual Behaviors in Children and Adolescents.

Prevent Child Abuse Vermont

Held at Azimuth Counseling & Therapeutic Services,

Essex Jct. VT

2 Contact Hours

July 30, 2008

Nurturing Healthy Sexual Development in Children

Prevent Child Abuse Vermont

Held at Azimuth Counseling & Therapeutic Services,

Essex Jct. VT

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2 Contact Hours

June 18, 2008

Plugged In: Technology, the Internet and Child Safety.

Prevent Child Abuse Vermont

Held at Azimuth Counseling & Therapeutic Services,

Essex Jct. VT

2 Contact Hours

September 21, 2007

When Bad Things Happen to Good Counselors

William Cote

Ethics Training sponsored by Vermont Addictions Professionals Association & Vermont

Alcohol Certification Board.

6 CEUs

March 22, 2007

Family Support: Coping With Illness and Loss

Gynecologic Oncology Outpatient Clinic at Fletcher Allen Health Care

Burlington, VT

Oct. 13, 2006

Treating Distress in Breast Cancer Survivors

9

th

Annual Breast Cancer and Women’s Health Conference, Psychology Track

Rose Coletti, Ph. D. & Joseph M. Patalano, Ph.D.

Sept. 29, 2006

Understanding Emotion: Creating Healthy Communities

Dr. Susan Deppe, sponsored by Azimuth Counseling & Therapeutic Services

3 CEUs

EXPERIENCE IN PRACTICE OF PSYCHOTHERAPY

March 2014 - Present: Peer Consultation, Azimuth Counseling Therapeutic Staff

September 2008 – March 2014: employed as psychotherapist at Azimuth Counseling &

Therapeutic Services, Essex Jct. VT, Supervisor: Christine Wilkens, LCMHC.

June 2011-January: Clinical Supervision provided by Christine Wilkens, LCMHC

September 2010-June 2011 Clinical Supervision provided by Rebecca Fitten LCMHC

September 2008 - August 2010 Clinical Supervision provided by Louise Dietzel.,Master's Level

Psychologist

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September 2007-May 2008: 800 Hour Internship, Azimuth Counseling & Therapeutic Services,

Essex Jct. VT Supervisor: Christine Wilkens, LCMHC, CASAC

Spring and Summer semesters 2007: 200 Hour Practicum, Azimuth Counseling and Therapeutic

Services, Essex Jct., VT Supervisor: Christine Wilkens, LCMHC, CASAC

Aug. 21, 2006 - Oct.16, 2006, assisted in Women’s Self-esteem group at Azimuth Counseling

and Therapeutic Services, Essex Jct., VT, supervised by Christine Wilkens

SCOPE OF PRACTICE

• Theoretical Orientation:

Cognitive-Behavioral and Client-Centered

• Treatment methods

Identify thought patterns (cognitions) and their underlying beliefs

Examine, evaluate and reframe thoughts that underlie limiting beliefs

Motivational Interviewing, strengths based

Narrative Therapy

Psychoeducation

Bibliotherapy

• Areas of special interest:

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VERMONT SECRETARY OF STATE OFFICE OF PROFESSIONAL REGULATION BOARD OF ALLIED MENTAL HEALTH PRACTITIONERS

UNPROFESSIONAL CONDUCT FOR NON-LISCENSED AND NON-CERTIFIED PSYCHOTHERAPISTS TITLE 26, VERMONT STATUTES ANNOTATED, CHAPTER 78, SECTION 4093

AND TITLE 3 CHAPTER 5 UNPROFESSIONAL CONDUCT § 4093. UNPROFESSIONAL CONDUCT

a) Unprofessional conduct means the following conduct and conduct set forth in section 129a of Title 3: 1) Providing fraudulent or deceptive information in an application for entry on the roster.

2) Conviction of a crime that evinces an unfitness to practice psychotherapy. 3) Unauthorized use of a protected title in professional activity.

4) Conduct which evidences moral unfitness to practice psychotherapy.

5) Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the psychotherapist has had a professional relationship within the previous two years.

6) Harassing, intimidating or abusing a client.

7) Entering into an additional relationship with a client, supervisee, research participant or student that might impair the psychotherapist's objectivity or otherwise interfere with his or her professional obligations.

8) Practicing outside or beyond a psychotherapist's area of training, experience or competence without appropriate supervision.

b) After hearing, and upon a finding of unprofessional conduct, the board may take disciplinary action against a rostered psychotherapist or an applicant.

Last amended: 1998 Legislative Session-Effective date: July 1, 1998 § 129a. UNPROFESSIONAL CONDUCT

a) In addition to any other provision of law, the following conduct by a licensee constitutes unprofessional conduct. When that conduct is by an applicant or person who later becomes an applicant, it may constitute grounds for denial of a license or other disciplinary action.

1) Fraudulent or deceptive procurement or use of a license. 2) Advertising that is intended or has a tendency to deceive.

3) Failing to comply with provisions of federal or state statutes or rules governing the practice of the profession. 4) Failing to comply with an order of the board or violating any term or condition of a license restricted by the board. 5) Practicing the profession when medically or psychologically unfit to do so.

6) Delegating professional responsibilities to a person whom the licensed professional knows, or has reason to know, is not qualified by training, experience, education or licensing credentials to perform them.

7) Willfully making or filing false reports or records in the practice of the profession; willfully impeding or obstructing the proper making or filing of reports or records or willfully failing to file the proper reports or records.

8) Failing to make available promptly to a person using professional health care services, that person’s representative, succeeding health care professionals or institutions, upon written request and direction of the person using professional health care services, copies of that person's records in the possession or under the control of the licensed practitioner. 9) Conviction of a crime related to the practice of the profession or conviction of a felony, whether or not related to the practice of the profession.

10) In the course of practice, gross failure to use and exercise on a particular occasion or the failure to use and exercise on repeated occasions that degree of care, skill and proficiency which is commonly exercised by the ordinary skillful, careful and prudent professional engaged in similar practice under the same or similar conditions, whether or not actual injury to a client, patient or customer has occurred.

11) Exercising undue influence on or taking improper advantage of a person using professional services, or promoting the sale of services or goods in a manner which exploits a person for the financial gain of the practitioner or a third party.

b) The burden of proof in a disciplinary action shall be on the state to show by a preponderance of the evidence that the person has engaged in unprofessional conduct.

c) After hearing, and upon a finding of unprofessional conduct, a board or an administrative law officer may take disciplinary action against a licensee or applicant.

d) In the case where a standard of unprofessional conduct as set forth in this section conflicts with a standard set forth in a specific board’s statute or rule, the standard that is most protective of the public shall govern.

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