Qualified Individual Training Registration and Certification Requirements

Please select the option(s) that best describes your reason for completing the Qualified Individual Training Registration and Attestation.*

For more details on our Qualified Individual Fundamental Courses, please visit our website: https://humanservices.ucdavis.edu/subject-areas/ffpsa-part-iv

I would like to sign up for (CSN TBA) Qualified Individual: 8/21, 8/28, and 9/9/2025 [9AM – 4PM PST]

I would like to sign up for (CSN TBA) Qualified Individual: 10/28, 10/31, 11/4, 11/7, 11/14, and 11/21/2025 [9AM-12PM PST]

I attended the Qualified Individual: Getting Started Webinar on September 2021

Verification Letter *Required

NOTE: To complete registration, CDSS requires a verification letter for upload. The verification letter should either be on the county letterhead or an email (converted to PDF) with an official county email address from the Supervisor or Program Manager and a signature block. The verification letter should contain the following information:

The agency has designated you as a Qualified Individual (QI) for the county or Tribe.
The agency has verified that all the requirements listed in ACL 21-113 are met.
Signature block of your supervisor or program manager.
Upload verification letter as a PDF.

File Upload*

Upload verification letter. See requirements above.

PLEASE UPLOAD THE VERIFICATION LETTER AS PDF*

Sample Verification Letter : CLICK HERE

Drag and drop files here or

Attestation of Objectivity

I meet the minimum qualifications required to serve as a Qualified Individual (QI) as specified in ACL 21-113/BHIN 21-060

Please select one of the following:*

I am a licensed mental health professional (LMHP), or

I am a registered professional working under the clinical supervision of a LMHP.

I am a waived professional working under the clinical supervision of a LMHP.

I am a trained professional working under the clinical supervision of a LMHP.

Both of the following qualifications are required for successful certification as a QI. Please confirm which qualifications you have completed. (Please select all that apply)

I have expertise and training in clinical assesment, treatment planning, and Intensive Care Coordination (ICC)*

I am certified to complete the Integrated Practce - Child and Adolescent Needs and Strengths (IP-CANS) assessment as directed in ACL 18-81/MHSUDS IN 17-052*

Date Integrated Practice - Child and Adolescent Needs and Strengths (IP-CANS) assessment certification was completed:*

*Note: Please provide the date of your last CANS certification. If the date listed is about to expire before or during the class dates, you will need to update your certification in advance. [MM/DD/YYYY]

This needs to be up to date to training

Please enter the date within the last year

I am a Qualified Individual*

Of a County Mental Health Plan or Behavioral Health Department or designated by a Tribe.

Serving under a state approved QI Waiver program (Tribal or County).

I am completing this QI training as an employee of the County Mental Health Plan or Behavioral Health Department. Please confirm the statement below is true. This is a requirement for successful certification as a QI.

I am not an employee of a county child welfare or juvenile probation placing agency and I am not connected to or affiliated with any facility or placement setting, such as a short-term residential therapeutic program, community treatment facility, foster family agency, or other residential facility, in which children, youth, or nonminor dependents are placed.*

I am completing this QI training to serve as a QI under a state approved QI Waiver program (Tribal or County). (Select either I or II.)*

I: I am an employee of a Title IV-E child welfare or juvenile probation county placing agency.

II: I am connected to or affiliated with, but I am not an employee of, a facility or placement setting, such as a short-term residential therapeutic program, community treatment facility, foster family agency, or other residential facility.

I am an employee of a Title IV-E child welfare or juvenile probation county placing agency, and both of the following are true:*

I do not hold responsibility as a county child welfare or juvenile probation case carrying worker for, nor am I in the chain of command of an individual who is directly or indirectly working on the case of, any child, youth, or nonminor dependent.*

I will not hold responsibility as a county child welfare or juvenile probation case carrying worker for, nor am I in the chain of command of an individual who is directly or indirectly working on the case of, any child, youth, or nonminor dependent and concurrently perform a QI assessment for that child, youth, or nonminor dependent.*

Explain how you are connected to or affiliated with a facility or placement setting, such as a short-term residential therapeutic program, community treatment facility, foster family agency, or other residential facility, in which children are placed by a county placing agency (i.e., a community-based provider).*

By checking this box, I attest and affirm the information herein is accurate and I have disclosed all potential conflicts of interest, and I will maintain objectivity in my role as a Qualified Individual in accordance with the generally accepted standards for clinical practice within my profession. I also acknowledge that I need to inform UCD of any changes to my status that impacts my role as a QI.*

Yes, I agree

No, I do not agree

General & Employer Information

*Required questions

First Name*

Last Name*

Work Email Address*

Work Phone*

Phone

Employer Name*

County or Tribal Affiliation*

County Department or Affiliation*

Child Welfare

Behavioral Health

Juvenile Probation

Designated by a Tribe

Job Title*

Employer Mailing Address*

Employer City*

Employer Zip Code*

Supervisor Information

*Required questions

Supervisor's First Name*

Supervisor's Last Name*

Supervisor's Phone Number*

Phone

Supervisor's Email*

Send me a copy of my responses

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