BMHC Renewal Form, Attestation, and Agreement

Thank you for your interest in maintaining a BMHC credential through the renewal process. Please complete all information in this application. Incomplete sections could result in increased length of the renewal process. Applicants who receive a core credential through the BMHC and elect to participate in the AACC’s comprehensive Christian Care Network understand that certain contact information (only business related and not personal), along with other pertinent demographic information (gender, age, ethnicity, years of experience, credentials, areas of specialization, etc.), may be listed in resource directories in order to assist those seeking help in making appropriate and/or desired choices for care.

Step 1 of 3

I. Demographic Information Update

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Practice/Organization/University/Church, etc., where you work and/or provide coaching/caregiving services(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone(Required)

Email(Required)

Fax

Secondary Phone / Emergency Phone

Cell Phone

Home Phone

VI. Renewal Agreement

Please check each box below indicating that you have read, understood, and consented to the statement.

CERTIFICATION(Required)

I hereby certify that all the information in this entire renewal application is true and complete. I understand that I have the burden of producing all the information necessary for the BMHC to fairly and fully evaluate my qualifications, background, ethics, and character in order to be considered for the renewal of my BMHC credential. I understand and agree to inform the BMHC as quickly as possible of any changes in this information. I agree that any misstatement or omission from this renewal application may be cause for denial of reappointment to the credential. I further agree that any subsequent adverse information about me or my practice and/or a violation of the AACC Code of Ethics and Mental Health Coaching Code of Ethics may be cause for disciplinary action – including the possibility of permanent expulsion from holding the credential – and that such action may be publically communicated in any form or forum the BMHC chooses to disclose such information.

AUTHORIZATION(Required)

I hereby authorize and give my consent to the BMHC to contact and, without restriction, discuss any issues pertaining to my character and qualifications with current and former supervisors, administrators, pastors, and/or other colleagues with whom I have worked. I authorize the BMHC to contact any professional and ministerial associations, to obtain whatever information it deems necessary to properly evaluate this renewal application. I hereby consent to the release of all information, records, and documents, by whatever means the BMHC chooses to collect this data, and to assist them in the good-faith evaluation of my renewal application. If a question arises in the future about my character and qualifications to the credential, I agree to assist the BMHC in its efforts to resolve any questions it may have about me. I further agree and consent to allow a copy of this agreement to be sent to anyone whom the BMHC deems necessary to assist them in resolving any and all questions about my worthiness to achieve and hold a BMHC credential.

INDEMNIFICATION(Required)

I release from any and all liability the BMHC, the AACC, the AACC Foundation, and any individual officers, directors, employees, or agents of these organizations for any and all acts done in good faith and without malice or intent to harm in connection with the evaluation of the renewal application for my BMHC credential. I further release from any and all liability, any persons or organizations that release information regarding this renewal application to the BMHC, and agree to hold harmless anyone who may make a negative or adverse judgment about my character or qualifications during the evaluation process.

DISPUTE RESOLUTION(Required)

If a dispute arises between me and the BMHC regarding this renewal application or any future matter, I agree to engage in dispute resolution that (1) first attempts direct negotiation; (2) then attempts mediation with a mediator acceptable to both parties; (3) then uses arbitration and binding arbitration to resolve the matter. The parties agree to abide by the Christian mediation rules of the Christian Conciliation Service (at www.hispeace.org) and the administrative rules and procedures of the American Arbitration Association for binding arbitration. The chosen rule of law and forum state shall be the Commonwealth of Virginia.

CREDENTIAL RESOLUTION(Required)

I resolve to support the mission and goals of the BMHC and I further agree to abide by and fully adhere to the AACC Doctrinal Statement, the AACC Code of Ethics and Mental Health Coaching Code of Ethics. I have not hidden, nor have I omitted any necessary information to honestly qualify for this credential. If I am reappointed, I will hold my BMHC credential in the highest regard, honor the calling of God in Christian mental health coaching, and maintain both excellence and an ethical stance as a servant-leader in this field. Furthermore, I will strive to avoid all stain of bad reputation and ill-repute upon the name of Christ, the cause of Christian mental health coaching, and the good purposes of the BMHC.

I, the undersigned, have read, discussed as needed, and fully understand this Renewal Application, Attestation, and Agreement. I understand that by signing this document, I do herby agree with all consent and authorization statements that are described herein.

I certify that the information provided is true and correct.(Required)

Yes

Name(Required)

First Last

Date(Required)

Renewal Fee(Required)

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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