STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING, Petitioner, vs. Case Number: 2001-00138 | - v7 CYNTHIA HAMBRICK, Ol 30 IY. C Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW, the Petitioner, Department of Health, hereinafter referred to as “Petitioner,” and files this Administrative Complaint before the Board of Clinical Social Work, Marriage and Family and Mental Health Counseling against CYNTHIA HAMBRICK, hereinafter referred to as “Respondent,” and alleges: 1. Effective July 1, 1997, Petitioner is the state agency charged with regulating the practice of mental health couns li ursuant to Section 20.43, Florida Statutes, Chapter 456, Florida contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils, or boards, as appropriate. 2. Respondent is and has been at all times material hereto, a registered Mental Health Counselor Intern, in the State of Florida, having been issued registration number IMH 1657. ' 3. Respondent’s last known address is 400 South 17° Street, Fernandina Beach, Florida 32034. s (formerly Chapter 455, Part II; see Chapter 2000-160, Laws of Florida), and Chapter 43 (3)(g), Florida Statutes, the Department has See perp The Respondent submitted to the Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling an application for licensure as a Mental Health Counselor. The Respondent was required to sign the application. The Respondent signed the application and dated it October 25, 2000. With the application submitted on or about October 25, 2000, the Respondent included Supervised Experience Forms documenting her postmaster’s clinical experience. One Supervised Experience form was signed by Carolyn Hillhouse Jones and states that the Respondent worked an average of 40 hours per week for 22 weeks (a total of 880 hours of supervised experience). One Supervised Experience form was signed by Robert Howart and states that the Respondent worked an average of 40 hours S Per week for 18 weeks (a total of 720 hours of supervised experience). In an undated letter to the Board, the Respondent admitted that she had falsified the supervision forms by inflating the number of supervision hours that she received. The Respondent subsequently submitted revised Supervised Experience forms. The revised form signed by Ms. Jones documented that the Respondent actually worked an average of 40 hours per week for 9 weeks (a total of 360 hours of supervised experience). The revised Supervised Experience form signed by Robert Howart documented that the Respondent actually worked an average of 40 hours per week for 6 weeks (a total of 240 hours of Based on the oregoing, the Respondent is s subject t to 0 discipline for violation of: Section 491. 009 2), Florida Statutes by attempting to obtain a license under this chapter by fraudulent misrepresentation; “or record. and Section 49 1009 Oe), Florida States, iy way making 0 or fling a false report ats WHEREFORE, Petitioner respectfully Tequests the Board of Clinical Social Work, Marg and ae . . Se Family Therapy, and Mental Health Counseling to enter an order imposing one or more Samia, 3 penalties: revocation or suspension of Respondent’s license; restriction of Respondent’s price Ge. imposition of an administrative fine; issuance of a reprimand; placement of the Respondent’s Ae probation for a period of time and subject to terms and/or conditions, and/or any other relief which the Board deems appropriate. SIGNED this Ole By: Nancy M. Snurkowski Chief Attorney General Counsel’s Office -MQA Practitioner Regulation — Legal COUNSEL FOR PETITIONER: Deborah B. Loucks w Fl LED Senior Attorney PARTMENS OF a Florida Attomey Number: 0169889 Agency for Health Care Administration Cont el Practitioner Regulation — Legal Post Office Box 14229 . Tallahassee, Florida 32317-4229 (850) 487 SOR RS OEE ETRE SON Pe ee ne eget

Docket for Case No: 01-003094PL