Cheryl Shive Professional Disclosure

Professional Disclosure Information
We disclose to each client the professional qualifications and experience of the supervised psychotherapist, those actions that constitute unprofessional conduct, and the method for filing a complaint or making a consumer inquiry.

Vermont Board of Allied Mental Health Practitioners

Non-Licensed and Non-Certified Psychotherapists

Cheryl Shive, M.S., MSW, LICSW - Resume

SUMMARY:

Broad experience in counseling at-risk children and adolescents in a school setting, community mental health center, in-patient facility, and private practice. Direct, practical experience with adolescents who have co-occurring disorders. Proven ability to quickly establish excellent working relationships with clients. Demonstrated capability to adapt to new situations and various program changes. Desire to shed light on issues surrounding children's social, emotional, and mental health. Seasoned, long-term foster parent to children and youth and transitional youth who are victims of abuse and neglect.

Skillful manager of non-governmental, non-profit social work processes including the development and implementation of a business plan, startup and ongoing management of operations as well as therapeutic care of children with diverse emotional, social and developmental needs. Educated, with highest honors, and certified mental health professional that is a thought and process leader with business and education leadership experience.

• Years of experience working with Children and Families
• Excellent Rapport With Clients
• Excellent Critical Thinking Skills
• Detail Oriented
• Strong Communication Skills
• Strong Conflict Resolution Skills
• Project and Management Experience
• Strong Writing Skills
• Proficient Organizer
• Excellent Leadership Skills

RELEVANT PROFESSIONAL EXPERIENCE:
Clinical Social Worker January 2019- Present
Matrix Health Systems
Vermont Center for Anxiety Care
112 Lake Street,
Burlington, VT 05401
• Practice in accordance with NASW values and Code of Ethics.
• Practice in a culturally affirming manner with diverse populations.
• Complete various intake and evaluation forms with clients.
• Provide therapeutic interventions and documentation including treatment goals and therapy notes.
• Family Counseling, Parenting Support, Individual, and Christian Counseling
• Continually assess client needs and communicate with primary care doctors and
psychiatrists.

Clinical Social Worker October 2017 – October 2018
Ten Ten Counseling, LLC
17320 Moore Rd,
Boyds, MD 20841
• Practice in accordance with NASW values and Code of Ethics.
• Practice in a culturally affirming manner with diverse populations.
• Complete various intake and evaluation forms with clients.
• Provide therapeutic interventions to the identified client populations in order to enhance the client’s optimal functioning and interactions in the home and community.
• Family Counseling and Parenting Support
• Continually assess client needs, service availability and appropriateness
• Provide the appropriate documentation for service delivery including treatment goals and therapy notes

Master’s Field Internship September 2016-July 2017
Behavioral Health Partners of Frederick
604 Solarex Ct., Suite 201
Frederick, MD 21703
Master of Social Work Intern Responsibilities:
• Provide individual and family therapy in schools and at client’s homes
• Document and perform biopsychosocial and mental health assessments
• Develop individual treatment plans
• Participate in interdisciplinary treatment team meetings
• Obtain insurance authorizations through Beacon Health

Master’s Field Internship September 2015-April 2016

The Jefferson School and Residential Treatment Center 2940 Point of Rocks Road Jefferson, MD 21755

The Jefferson School and Residential Treatment Center is a 12-month special education day school and residential school, located 15 minutes from Frederick, Maryland, serving students ages 12 to 21 with severe emotional and behavioral disabilities who need a specialized educational environment, complete with a therapeutic milieu and recreational and community-based activities.

Master of Social Work Intern Responsibilities:
• Participate in individual therapy for clients
• Co-Lead Dialectical Behavioral Therapy skills and homework group
• Participate in case management for caseload
• Involved in treatment teams
• Work cooperatively with other staff members in managing and facilitating treatment/care
planning for clients
• Participate in unit program development/ improvement
• Involved in Quality Evaluation of programs
• Participate in Discharge Planning and coordinator of services
Creator and Director September 2009-Present Faith Home Ministries
• Managed the startup of non-profit organization including business plan, construction and initial operations.
• Managed business and construction logistics including daily interaction and management of trades and disciplines such as finance, budget, policy, procedure, engineering, electricians, plumbers, project managers, architects, retailers, etc.
• Managed startup team including the assistant project manager, with construction details that included procurement of materials, construction, and charitable donations
• Manage ongoing financial management for the organization, achieving debt-free, operational surplus every year since inception
• Development of rules, guidelines, policy and procedure for organizational functions including objectives, goals, long-term planning, and operations
• Frequent, extensive interaction with children in therapeutic care, including broad care teams consisting of social workers, lawyers, government social service departments, biological parents and court systems and processes, providing for the children’s physical, emotional, social, spiritual and developmental needs

ACCOMPLISHMENTS: Years of therapeutic care excellence, meeting the needs of children in Montgomery and Fredrick Counties. Received Proclamation of Commendation July 31, 2012 from the County Council of Montgomery County, Maryland for “untiring devotion to children in crisis and for making a difference in the lives of children in their home well-beyond the time they temporarily share a home.”

Lovaas Behavioral Therapist September 1998 - February 2000 Cheverly, MD
• Home care therapeutic service for autistic children as a Lovaas method behavioral therapist
• Implemented plan training, materials and activities for student
• Documented applied behavior analysis results and treatment results.

Research Assistant University of Maryland, College Park College of Behavioral and Social Sciences, Center
for Child Studies April 1998 - April 2000
College Park, MD
• Worked on team research project sponsored by Children’s National Medical Center and the University of Maryland, College Park Center for Child Studies to determine the difference in foster children raised in a kinship versus non-kinship foster home
• Responsible for intake of research material via filming and documentation
• Participated in weekly status and analysis meetings
• Frequent travel to remote sites for data gathering, documentation and field work and to hospital setting for research material acquisition and compilation
• Daily interaction with kinship foster parents, non-kinship foster parents, foster children, fellow research assistants, and behavioral scientist.

Lovaas Approach Therapist February 1994 – April 1996 Laurel, MD
• Home care therapeutic service for autistic children as a Lovaas method behavioral therapist
• Participated in Lovaas Institute training program for children diagnosed with autism or related disorders and implemented the training and materials into treatment program
• Documented applied behavior analysis results and treatment results.

EDUCATION, CERTIFICATIONS, MEMBERSHIP & HONORS:
- Vermont Medical Reserve Corps Mental Health Volunteer; Chittenden and Addison Counties September, 2018-present
- Volunteer American Red Cross Disaster Mental Health Responder September, 2018-present
- Master of Social Work, Summa Cum Laude July 2017 Mental Health Specialization University of Maryland, Baltimore
- Master of Science, Psychology, Summa Cum Laude September 2012 University of Phoenix Bachelor of Arts, Psychology, Cum Laude May 2000 University of Maryland, College Park
- SBIRT Certification November 2015 University of Maryland, Baltimore School of Social Work Understanding the Behaviors of Traumatized Children Training Certificate April 2013 University of Maryland, Baltimore School of Social Work
- The County Council of Montgomery County Maryland Proclamation July 2012
  “for their untiring devotion to children in crisis and for making a difference in the lives in those children well beyond the time they temporarily share a home.”
- Attachment Disorder & the Family Training Certificate March 2012 University of Maryland, Baltimore, Child Welfare Academy
- Behavior Management Skills & Techniques Certificate 2010 - 2011 University of Maryland, Baltimore School of Social Work
My practice is also governed by the Rules of the Board of Allied Mental Health Practitioners. It is unprofessional conduct to violate those rules. A copy of the rules may be obtained from the Board or online at www.wec.state.vt.us

Information concerning unprofessional conduct for this profession posted in common area.

CLIENT AND/OR LEGAL GUARDIAN'S DISCLOSURE CONFIRMATION

My signature acknowledges that I have been given the professional qualifications and experience of Cheryl Shive, M.S., MSW, a listing of actions that constitutes unprofessional conduct according to the Vermont Statutes, and method for making a consumer inquiry to filing a complaint with the Office of Professional Regulations. This information was given to me no later than my third office visit.
Client Name:

First NameLast Name
Client Signature:

Clear
Date:

MonthDayYear
Date
Legal Guardian Name:

First NameLast Name
Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
____________________________________________________________________________

Cheryl Shive, M.S., MSW Date

VERMONT SECRETARY OF STATE

OFFICE OF PROFESSIONAL REGULATION

BOARD OF ALLIED MENTAL HEALTH PRACTITIONERS

UNPROFESSIONAL CONDUCT FOR NON-LICENSED AND NON-CERTIFIED

PSYCHOTHERAPISTS

TITLE 26, VERMONT STATUTES ANNOTATED, CHAPTER 78, SECTION 4093

AND TITLE 3 CHAPTER 5 UNPROFESSIONAL CONDUCT

The Office of Professional Regulation provides Vermont licensees, certifications, and registrations for over 37,000 practitioners and businesses. Thirty-nine professions and occupations are supported and managed by this office. A list of professions regulated is found below.

Each profession or occupation is governed by laws defining professional conduct. Consumers who have inquiries or wish to obtain a form to register a complaint may do so by calling 802.828.2372, or by writing to the Director of the Office, Secretary of State, 26 Terrace Street, Drawer 09, Montpelier, Vermont, 05609-1106.

Upon receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the governing body.

All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public.

Complaint investigations focus on licensure and fitness of the licensee to practice. Disciplinary action, when warranted, ranges from warning to revocation of license, based on the circumstances. You should not expect a return of fees paid or additional unpaid services as part of the results of the process. If you seek restitution of this nature, consider consulting with the Consumer Protection Division of the Office of the Attorney General, retaining an attorney, or filing a case in Small Claims Court.

Accountancy, Acupuncture, Architects, Athletic Trainers, Auctioneer, Barbers & Cosmetologists, Boxing Control, Chiropractic, Dental Examiners, Dieticians, Electrolysis, Professional Engineering, Funeral Service, Hearing Aid Dispensers, Land Surveyors, Marriage and Family Therapists, Clinical Mental Health Counselors, Midwives (Licensed), Motor Vehicle Racing, Naturopaths, Nursing, Nursing Home Administrators, Occupational Therapists, Opticians, Optometry, Osteopathic Physicians & Surgeons, Pharmacy, Physical Therapists, Private Investigative & Security Services, Psychoanalyst, Psychology, Psychotherapists (Non-Licensed), Radiologic Technology, Real Estate Appraisers, Real Estate, Social Workers (Clinical), Tattooists, Veterinary

Chapter 78: Roster of Psychotherapists Who Are Non-licensed

§§ 4090. Disclosure of information

The board shall adopt rules requiring persons entered on the roster to disclose to each client the psychotherapist’s professional qualifications and experience, those actions that constitute unprofessional conduct, and the method for filing a complaint of making a consumer inquiry, and provisions relating to the manner in which the information shall be displayed and signed by both the rostered psychotherapists and the client. The rules may include provisions for applying or modifying these requirements in cases involving institutionalized clients, minors and adults under the supervision of a guardian. (Added 1993, No. 222 (Adj. Sess.), §§ 17; amended 1997, No. 40, §§ 69.

§ 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 and 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 psychotherapists or an applicant. (Added 1993, No. 222 (Adj. Sess.) §§ 17; amended 1997, No. 40, §§ 71; 1997, No. 145 (Adj. Sess.), §§ 61; 1999, No. 52, §§ 37.)

Unprofessional Conduct Standards

Title 3, Chapter 5

§ 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. Any one of the following items, or any combination of items, whether or not the conduct at issue was committed within or outside the state, shall constitute unprofessional conduct:

(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 an 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) Failure to practice competently by reason of any cause on a single occasion or ON multiple occasions may constitute unprofessional conduct.

(c) Failure to practice competently includes:

(1) Performance of unsafe or unacceptable patient or client care; or

(2) failure to conform to the essential standards of acceptable and prevailing practice.

(3) 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.

(d) 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, including imposing an administrative penalty not to exceed $1,000.00 for each unprofessional conduct violation. Any money received from the imposition of an administrative penalty imposed under this section shall be deposited in the general fund.

(e) 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 of rule, the standard that is most protective of the public shall govern.

Last Amended: 2002 Legislative Session - Effective July 1, 2002 (H. 761)

CLIENT AND/OR LEGAL GUARDIAN'S DISCLOSURE CONFIRMATION

My signature acknowledges that I have been given the professional qualifications and experience of Cheryl Shive, M.S., MSW, a listing of actions that constitutes unprofessional conduct according to the Vermont Statutes, and method for making a consumer inquiry to filing a complaint with the Office of Professional Regulations. This information was given to me no later than my third office visit.
Client Name:

First NameLast Name
Client Signature:

Clear
Date:

MonthDayYear
Date
Legal Gaurdian:

First NameLast Name
Legal Gaurdian Signature:

Clear
Date:

MonthDayYear
Date
____________________________________________________________________________

Cheryl Shive, M.S., MSW Date
Should be Empty:

Professional Disclosure Information