Inactive/Extension

FOR EITHER TYPE OF REQUEST:
Requests for Inactive status and extensions of Inactive status may be submitted within the 3 months prior to the expiration date and require a $100.00 fee. If the request is submitted after the expiration date, but within 3 months, the request can be processed, but must include a $100.00 late fee. Requests cannot be accepted more than 3 months after the expiration date.

You will be notified by email of the decision regarding your request. If your request for Inactive Status is approved, you may not engage in the practice of behavioral health until you have reactivated your license pursuant to A.A.C. R4-6-305(F).

Please fill out all the fields for the Inactive Fee for $100.

First Name

Middle Name

Last Name

Email

@

Phone Number

#

Address

City/Town

State/Province

ZIP/Postal Code

License Informaion

License Number

#

Expiration Date

Late Fee $100

If you are completing after the expiration date, you must pay the $100 Late Fee.

Inactive/Extension

Is this your first inactive status request or an extension to a previously requested/approved inactive status request?

Initial

Extension

Per Board rule, extensions to inactive status require demonstration of good cause which is defined as: illness or disability, active military service, or a circumstance beyond the control of the licensee.

I understand that my request must be approved at an upcoming Board meeting and I have enclosed documentation validating my Good Cause reason

Illness or Disability

Active Military Service

Circumstance Beyond Licensee's Control

Please explain the reason for the request below:

Please upload a document to that request.

One file only.
10 MB limit.
Allowed types: pdf.

I acknowledge that pursuant to A.A.C. R4-6-215(C), application fees in subsections (A)(1) and (2) are non-refundable and other fees established in subsection (A) are not refundable unless the provisions of A.R.S. § 41-1077 apply. * *