Application Form
Introduction and Purpose of the Program

KRS 403.7505 authorizes the Cabinet for Health Services to promulgate administrative regulations to create a domestic violence certification program for mental health professionals. The program is specifically designed to certify those professionals who provide court-ordered domestic violence offender treatment, it does not regulate services to victims except with respect to how collateral contacts with victims are to be made by offender treatment providers. This program is also limited in scope to court-mandated services to domestic violence offenders.

The purpose of the program is to ensure victim safety through the provision of quality treatment services to domestic violence offenders. The program is also intended to provide for an organized referral resource for the Kentucky court system.

Qualifications of Certified Providers

The administrative regulations for domestic violence offender treatment program providers allow certification at two levels for mental health professionals, autonomous providers who shall be licensed or certified mental health professionals (unless grandparented into the program by January 1999) and associate providers who may only operate under the supervision of an autonomous provider. Specific requirements for both levels of certification are described in detail within the administrative regulations. Clinical experience, baseline training and continuing education are also required.

Procedures for Certification

Mental health professionals interested in becoming certified offender treatment providers for their local court system shall make written application to the Department for Mental Health and Mental Retardation Services, Sexual and Domestic Violence Program. Applicants must include documentation of education, experience, training and, for associate providers, a signed supervision contract. The Cabinet shall approve or deny the application in writing no later than 60 days after receiving a complete request for certification. Certification lasts for two years.

The attached application should be submitted to:

Sexual and Domestic Violence Program

Department for Mental Health/Mental Retardation Services

100 Fairoaks Lane, 4th Floor

Frankfort, Kentucky 40621-0001


Applicant Name:




Social Security Number:


Please Attach All Required Information in the Order Shown Below:

I. Written Request for Certification

II. Documentation of Qualifications


III. Documentation of Experience

IV. Documentation of Training

V. Documentation of Supervision

VI. Documentation of Curriculum

VII. Recommendations


VIII. Signature (for all applicants)

I agree to abide by all requirements set forth in administrative regulation 908 KAR 2:210E as it relates to domestic violence offender treatment certification. I understand that if I violate any of the standards as provided in the regulation, the Cabinet is empowered to revoke or deny my certification. I also understand that certification is good for two years and is contingent upon receipt of eight hours of continuing education annually.

I certify that the information given in this application form is correct and complete to the best of my knowledge. I am aware that falsification of any information may result in denial or revocation of certification. I hereby authorize the Cabinet to make all necessary verification concerning me or my agency and further authorize each educational institution, licensure or certification board, or organization to provide all information that may be needed in connection with my application.

I certify that I have not been convicted of any felony offense or any misdemeanor offense involving a crime against a person and that I have not had a domestic violence protective order issued against me within the past two years.

Signature of Applicant:



To Be Completed and Signed By Work Supervisor

I certify that ___________________________________________________(Applicant Name) has completed _______ hours of clinical work providing domestic violence services. This experience was divided approximately as follows:

__________ hours working with domestic violence offenders

__________ hours working with domestic violence victims

I further certify that I provided __________ hours of clinical supervision to the applicant.

As a result of my supervision and experience with the applicant, I:

__________ recommend him/her for certification

__________ do not recommend him/her for certification

__________ will not offer a recommendation

Printed Name of Supervisor:

Degree of Supervisor (including license or certificate number):

Signature of Supervisor:




Date of Signature:


Application for Certification

1) The Cabinet shall certify an individual as an associate provider or an autonomous provider if:

(a) the applicant meets the applicable qualifications specified in the administrative regulation; and

(b) if an applicant that requests certification as an autonomous provider meets all the requirements specified except an advanced degree and clinical supervision and requests certification before January 1, 1999.

2) The Cabinet may determine that a request is incomplete if:

(a) the documentation of qualifications is insufficient to meet the applicable qualifications; or

(b) the Cabinet can not verify the authenticity of the documentation of qualifications.

3) If the Cabinet determines that a request is incomplete it shall return the request to the sender and specify additional documentation that is required or the documentation that can not be verified.

4) The Cabinet shall approve or deny the request for certification in writing no later than sixty (60) days after receiving a complete request for certification.

5) Certification shall be effective for two (2) years.

6) The Cabinet shall renew the certification of an associate provider or an autonomous provider upon request if the provider submits documentation of completion of at least eight (8) hours per year of continuing education related to domestic violence.

Denial Or Revocation Of Certification

1) The Cabinet may deny a request for certification or revoke the certification of a provider if the Cabinet determines that the provider:

(a) has been convicted of a criminal offense including misdemeanors if the crime is against persons; or

(b) has had a domestic violence protective order issued against the applicant or provider within the previous two (2) years; or

(c) has an alcohol or other drug abuse problem as defined in KRS 222.005; or

(d) has had sanctions applied against any licensure or certification held by the applicant or provider at any time in the past two years; or

(e) has provided domestic violence offender assessment or treatment services without supervision if supervision is required by administrative regulation; or

(f) has falsified any information in a request for certification; or

(g) has failed to meet the requirements for maintenance of certification set forth in the administrative regulation; or

(h) has failed to implement a corrective action plan imposed by the Cabinet in accordance with the administrative regulation.

2) An applicant or a provider may appeal a denial of a request for certification or a revocation of certification. An appeal shall:

(a) be submitted in writing to the Sexual and Domestic Violence Program Specialist, Department for Mental Health and Mental Retardation Services Division of Mental Health; and

(b) specify the reason the provider believes the denial or revocation is unwarranted and;

(c) may include information or documentation supporting the appellant’s position.

3) If an applicant or a provider appeals a certification decision the Cabinet shall appoint a hearing officer and conduct an administrative hearing in accordance with KRS 13B.


1) The Cabinet shall:

(a) investigate signed written complaints received about providers if the complaints allege a failure to comply with the provisions of this administrative regulation; and

(b) refer any complaints against providers which relate to unethical practice or practice which may be outside the practice of a provider to the appropriate licensure or certification board.

2) The Cabinet may evaluate a certified provider’s adherence to the provisions of this administrative regulation on its own initiative.

3) Monitoring by Cabinet staff may include any of the following activities:

(a) interviewing offenders or victims if they consent to be interviewed;

(b) reviewing service records maintained by providers on offenders that have been referred by a court in accordance with this administrative regulation;

(c) direct observation of services provided to offenders unless an offender objects to being observed;

(d) interviewing judicial, correctional, or police officials, and other agency personnel that interact regularly with a certified provider in relation to offender services.

(4) If the Cabinet determines that a certified provider has failed to comply with provisions of this administrative regulation the Cabinet shall notify the provider in writing of its determination and may:

(a) require the provider to submit a corrective action plan; or

(b) impose a corrective action plan upon the provider; or

(c) revoke a provider’s certification

5) The Cabinet shall notify an autonomous provider that supervises an associate provider ifit determines that an associate provider has failed to adhere to the provisions of this administrative regulation.


Autonomous Providers

Associate Providers


1) A certified associate provider may under the supervision of an autonomous provider:

(a) screen, assess, plan and provide treatment services under the supervision of an autonomous provider to offenders and clients of a program; and

(b) consult with the courts, prosecutors, law enforcement, other agencies, mental health providers and others regarding the assessment or treatment needs of clients; and

(c) have collateral contacts with victims (with the permission of the victim).

2) A certified associate provider shall participate in at least one (1) hour per week of face-to-face supervision dedicated to case discussion, review of reading assignments, skill building, and review of audio or video tapes of actual clinical practice provided by the associate provider.

3) A certified autonomous provider may provide screening, assessment, treatment and consultation services independently and supervise associate providers if he or she has:

(a) participated in a three hour training program in clinical supervision that has been approved by a mental health licensing board or by the cabinet; and

(b) been in the practice of domestic violence offender treatment for a period of at least one year.

4) A certified autonomous provider who supervises associate providers shall:

(a) provide supervisees the supervision required by administrative regulation; and

(b) directly observe the supervisee’s practice in person or through video or audio tapes of the supervisee’s clinical practice; and

(c) assure that supervisees provide services in accordance with the all the provisions of the administrative regulation.

5) A supervisor shall not supervise more than six associate providers concurrently.



General Service standards

1) Services provided to offenders referred by a court for domestic violence services shall be based on the following premises regarding violent conduct, the roles of offenders, and the effects of domestic violence on victims:

(a) domestic violence constitutes a health hazard to victims who may experience short and long term effects from the abuse. Immediate and long term cessation of the domestic violence is the priority purpose for treatment.

(b) domestic violence in its various forms is criminal behavior.

(c) services shall be designed to enhance and promote the safety of identified and identifiable victims including spouses, live-in partners, children and other family members.

(d) victims are not responsible for the violent behavior of offenders and services shall not promote the concept of mutual responsibility in explaining domestic violence.

(e) the offender is accountable for domestic violence which is the product of individual choice and learned traits. The offender’s psychopathology, substance abuse, other disorders, or cultural background are not explanatory causes of the offenses but can influence the offender’s behavior.

(f) cooperation and service coordination between law enforcement, the courts, probation and parole agencies, the Department for Social Services, spouse abuse centers and other victim advocates, chemical dependency professionals, and other mental health professionals is necessary to assure effective treatment and the safety of victims and potential victims.

2) A provider shall document all services provided to offenders that receive domestic violence services pursuant to a referral by a court. Service records shall reflect that the services have been provided in accordance with subsection (1) of this section.

3) An offender may consent or refuse to receive domestic violence services provided in accordance with the requirements of this administrative regulation at any time.

4) A provider shall treat offenders with respect and dignity at all times and shall not discriminate against an offender based on race, ethnicity, gender, age, religion or disability.

5) An offender shall have the right to complain verbally or in writing to the provider, the referring court, or the Cabinet and a provider shall not take any adverse action against an offender that makes a complaint.

6) A provider shall adjust fees based upon the client’s ability to pay. If a court has made a finding prior to making a referral for treatment that a client is indigent, a court may order a client to perform community service in lieu of payment of a fee.

7) A provider shall comply with any and all federal laws pertaining to research with human subjects and shall protect the privacy of any clients who give consent to participate in any provider sponsored research activities.

8) The provider shall provide clean and comfortable facilities for client services that meet applicable fire safety codes and handicapped accessibility codes.

9) The provider shall comply with all federal and state laws applicable to the confidentiality of client records

10) Victims may participate in screening, assessment or treatment services subject to the provisions of subsection 6 of this administrative regulation if an offender and the victim consents to a victim’s participation.

Collateral Contacts With Victims

1) If an offender consents to a victim’s participation in assessment or treatment services a provider shall:

(a) attempt to contact the victim within five days of the offender’s admission to the program; and

(b) offer the victim an opportunity to participate in the assessment or treatment of the offender by disclosing information about the offender and the circumstances of the violence; and

(c) interview victims who consent to participate in an assessment of the offender; and

(d) provide the victim information about the program, its possible benefits, the limitations of services, and the degree to which the offender’s participation may or may not result in increased safety for the victim;

(e) educate the victim about community services which are available to assist in meeting current or future protection needs of the victim and family members.

2) Providers shall document their efforts to contact victims.

3) Victim interviews shall not be conducted in the presence of the offender

4) If a victim does not consent to participate, or withdraws consent to participate, or refuses to participate or provide information, a provider shall not attempt to coerce or persuade the victim to participate.

Screening Procedures

1) A provider shall establish:

(a) eligibility criteria which may include an offender’s admission of responsibility for a domestic violence related offense and may not be based solely on an offender’s inability to pay for services; and

(b) procedures for acceptance of referrals of offenders from a court following charges of a domestic violence related offense or as a condition of a protective order issued pursuant to KRS 403; and

(c) notification of the referring court if an offender is determined not to be eligible for aprovider’s services including the reasons therefore and any referrals made in accordance with the administrative regulation no later than five (5) days after the decision.

2) An offender shall be provided with all of the following information prior to receiving assessment or treatment services:

(a) the limitations on confidentiality including the duties of providers to warn and protect intended victims of threats to harm under the provisions of KRS 202A.400 and the fact that information disclosed to the provider or other clients may be used against them in civil or criminal proceedings;

(b) the relationship of the provider to the referring court including duties to make reports pertaining to the client to the courts, prosecutors, probation and parole officers, law enforcement, the victim, and any other named party or agency that might be involved in the coordination of the client’s services;

(c) the offender’s responsibility for paying fees for services and policies regarding non-compliance with payment of fees;

(d) the expected length of treatment participation and the terms for discharge from the program including grounds for involuntary discharge;

(e) An explanation of the requirements of the administrative regulation;

(f) An explanation of the rights set forth in the administrative regulation;

(g) A description of the services that will be provided including requirements for participation; and

(h) notification that, at the discretion of the court, failure to comply with program requirements may result in a citation for contempt of court; and

(i) an explanation of procedures for victim participation in screening, admission and treatment services.

Assessment and Admission Procedures

1) If an offender is determined to be eligible for domestic violence services offered by the provider an assessment of the offender’s treatment needs shall be performed. The assessment shall include consideration of the offender’s:

(a) history of abusive behavior including degree of harm and type of violent conduct;

(b) criminal history;

(c) risk of harm to self and others;

(d) medical history;

(e) history of mental or emotional disorder;

(f) current mental status;

(g) the presence of any co-occurring disorders such as mental illness or substance abuse or dependence;

(h) the offender’s ability to benefit from English language services and from group settings; and

(i) may include a review any relevant public records, police reports and other available collateral sources of information on the offender.

2) A provider may interview a victim subject to the provisions of the administrative regulation and consider information provided by a victim in the assessment if an offender consents for a victim to participate in an assessment.

3) If, upon assessment, a provider determines that the offender is unlikely to benefit from services due to a high risk of lethality or other factors a provider shall refer the offender to services more likely to benefit the offender.

4) A provider may refer an offender to mental health or substance abuse treatment services as a prerequisite for admission or completion of a domestic violence offender treatment program.

5) A provider shall notify the referring court no later than five (5) days after making a determination based on an assessment if the offender shall be admitted or not, and referrals made, if any.

6) An offender shall be admitted for domestic violence treatment upon providing a written consent for treatment and agreeing writing to comply with all program rules and guidelines and providing written authorization for a provider to release information to all the referring or service coordinating parties identified above

Treatment Procedures

1) A provider shall make individual and group services available to clients at least once weekly.

2) A program shall offer separate groups for male and female offenders

(a) group services may involve a minimum of two clients but shall not exceed twelve clients at any time unless two providers facilitate each group session.

3) If two providers facilitate a group, it may include a total of fifteen participants.

4) Group services shall be scheduled in at least one and one-half hour sessions.

5) A client shall participate for a minimum period of 20 weeks and a recommended period of 50 weeks.

6) Non-court-referred clients may participate in group services with court referred clients.

7) The provider shall establish a core curriculum for group participation that covers the essential features of domestic violence including:

(a) Definition of domestic violence in its various forms, including physical, sexual,psychological and environmental abuse;

(b) Exploration of the effects of domestic violence on victims and witnesses;

(c) Discussion of the legal dimensions of domestic violence;

(d) Description of the cycle of violence and other dynamics of domestic violence;

(e) Instruction of clients about their responsibility for the domestic violence behavior;

(f) Confrontation of the client’s use of power, control and coercion in intimate relationships;

(g) Confrontation of rigid sex role stereotypes;

(h) Challenge of the client’s pattern of aggressive reactions in conflict situations with victims;

(i) Exploration of the actual and perceived role of alcohol and drug abuse in the domestic violence;

(j) Exploration of constructive and non-violent methods for expressing anger and resolving conflict in relationships, including the use of "time outs," stress management, anger reduction and constructive verbal methods for resolving conflict;

(k) Encouragement of the client’s contribution to restitution to the victim and family members;

(l) Development of relapse prevention techniques; and

(m) Promotion of aftercare services where indicated.

8) If group services for female offenders are offered, the required curriculum may be amended to relate specifically to female offenders.

9) A provider shall execute all duties to warn and protect if intended victims have been threatened by a client of the program under the provisions of KRS 202A.400.

10) A provider shall notify the victim of the discharge or termination of a client.

11) A provider shall not offer or provide marital counseling or therapy to any client or victim until the client has successfully completed the program and has demonstrated at least 6 months of nonviolent behavior in the relationship.

12) A provider shall not offer or provide marital counseling or therapy to any client or victim if there is a foreseeable risk of harm to the victim resulting from the marital services or if a provider believes that the victim may be agreeing to participate because of coercion or threat from the offender.

Involuntary Discharge From a Program

1) A provider shall dismiss from the program any offender that:

(a) fails to attend more than ten percent of scheduled appointments; or

(b) fails to actively participate in services or complete assignments; or

(c) fails to assume financial responsibility for services as ordered by the court; or

(d) violates any provision of a court order; or

(e) reports a reoccurrence of domestic violence.

2) A provider shall notify the referring court no later than five (5)days after a decision to discharge an offender from the program and shall specify the reason for the discharge.