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Dr. Maria Zayas Bazan _ MIAMTEACH CI Y OF MIAMI BEACH BOARDS ADD COMMITTEE APPLICATION FORM NAME: %5 -,- ZA-?-A N W!�R:Lft• . Last Name ^ \ n� First Name Middle Initial HOME ADDRESS:,_),3o &tJ 26 3 �' 3 Sod 1 No. Street City State Zip Code PHONE: 3 o s 15 .5 O_:? M f1i't rr�n zau!as 6Q-�iGt.4l)• �M _wertte- ce ` Work Fax Email ad ress Business Name: Position: (4 Q,Jn Address: a"AA 11 1102424 rc' No. _ Street City State Zip Code Professional License(describe Expires: Attach a copy of the license Pursuant to City Code section 2-22(4)a and b: Members of agencies, boards, and committees shall be affiliated with the city; this requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six months; or b)an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six(6) months: Yes❑or No C� • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6) months: Yes YborNo ❑ • Are you a registered voter in Miami Beach: Yes ❑or No • (Please check one): I am now a resident of: North Beach ❑South Beach ❑ Middle Beach ❑ • I am applying for an appointment because I have special abilities, knowledge, experience. Please list below: ComQS�%e 6 ole n&, CA •I ri f ` SI t Please list your preferences in order of ranking [1] first choice[2] second choice, and [3]third choice. Please note that only three(3) choices will be observed by the City Clerk's Office.(Regular Boards of City) ❑Art in Public Places Committee 0 Housing Authority* ❑Beach Preservation Board 0 Loan Review Committee* ❑Beautification Committee ❑Mayor's Green Ad-Hoc Committee 0 Board of Adjustment* ❑Marine Authority* ❑Budget Advisory Committee 0 Miami Beach Cultural Arts Council ❑Committee on Homeless 11"iami Beach Commission on Status of Women ❑Committee for Quality Education in MB ❑Miami Beach Florida Sister Cities ❑Community Development Advisory* ❑Normandy Shores Local Gov't Neigh. Improvement Community Relations Board 0 Oversight Committee for General Obligation Bond ❑Convention Center Advisory Board ❑Parks and Recreation Facilities Board ❑Debarment Committee ❑Personnel Board* ❑Design Review Board* ❑Planning Board* ❑Disability Access Committee ❑ Police Citizens Relations Committee ❑Fine Arts Board 0 Production Industry Council ❑Golf Advisory Committee 0 Public Safety Advisory Committee ❑Health Advisory Committee ❑Safety Committee 0 Health Facilities Authority Board 0 Transportation and Parking Committee 17 Hispanic Affairs Committee 0 Visitor and Convention Authority* ❑Historic Preservation Board* ❑Youth Center Advisory Board *Board Required to File State Disclosure form C.t[:iccurncnts and Ie!uR)rary lnternet f iiesV:11,MC5M,3C.,Application Reuisod July 18 2,OC7.doc. Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes❑No❑ Years of Service: 2. Present participation in Youth Center activities by your children Yes❑ No ❑. If yes, please list the names of your children, their ages, and which programs. List below: Child's name: Age: Program: Child's name: Age: Program: *Have you ever been convicted of a felony: Yes 0 or No✓If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes❑or No V*'If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes❑or No Gt' If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes ❑or No �. If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? r_ _ Name: Title: .e r n,� 6 S Name: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: �1 u ��neo�,►.�po�cT� W00 � •L C• 31 a Q & o� • I am now employed by the City of Miami Beach: Yes� or No❑. Which department? o Pursuant to City Code Section 2-25(b): Do you have a parent❑, spouse❑, child❑, brother❑, or sister❑who is employed by the City of Miami Beach?Check all that apply. Identify the department(s): Nonce This section is"not required"but desired: Age: q.L years old Gender: Male❑ Female k_,� Ethnic Origin (Check one) / White❑African-American/Black 0 Hispanic: 54 Asian or Pacific Islander 0 American Indian or Alaskan Native❑ Employment Status: Employed V1RetirHome-maker❑Other❑ "I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII— f tandards of Conduct for City Officers, Employees and Agency Members." Rz A �$ n Da a Name of Applicant(PLEASE PRINT) Please attach a copy of your resume to this application NOTE:Applications will remain on file for a period of one(1)calendar year. Received in City Clerk's Office by Date Name of Deputy Clerk Document Control Number(Assigned by the City Clerk's Office) Z,z- Entered By Date 3v R ised 125/07 jo 2 G',[Docunit;rits and Internet ;gip ication Revised.lu'y 18 2007.doc L.L W O �Lu Z W �. ao 6,Z Z. -4 0 p LO p W Ln z •' C/) .V: Q� = N 2W =< Q CD fe- A WQ p , w Z W..W;Q W W CO. Q_ W =O O cd r Q d � L) 0- W LL..:-. :. . 2 Q) d= p Z Q.N O M Q.'M W Cl) _ .Q2 = Z2.H w OF . U to � . ¢ � - "p W N Q N Q Z w OV Z tom- 0 Q Z m = 0 W -' m W E o ¢m v� � � � _..E. �.. r. a� } W Ow.; C) .,w ._E W L Z M '0 f�. N Q M N 3; Q V ""3 Z o c W ,N CO .c Q W y -J _ V � mU- ' ° J aZ � LO (� N E (D 0 a r ¢ cco < L �° c X S <r S 5 w V z _ .. U)W. O 00 W J " M ' co cp Lu . O . TF- � .0 Q O :Lul LU } w CO z w O'IL Q:: _... ..z r w G% �.Z w 0 LU w >- Q" Lu Q O C6 J � a �. :.. :.:.. Q D- 79 2 W es., C w p0. � G = � o Z Z O 0 N o O ^N Lu -N - 6 M Q p P �_ G >- N N O UZ C�! 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Zayas-Bazan, LM HC, Psy.D. 1111 Lincoln Road, Suite 400 Miami Beach, Fl 33129 (305) 815-5903 EDUCATION 2001 Doctor of Psychology Carlos Albizu University Miami Campus 1994 Master of Science in Psychology Miami Institute of Psychology Caribbean Center for Advanced Studies Graduated with Utmost Distinction 1993 Bachelor of Arts in Psychology University of Miami 1989 Associate of Arts in Psychology Miami Dade Community College, North Campus LICENSUREXERTIFICATION 2007 Licensed Psychologist in the state of Florida(License# PY7521) 2003 Hypnotherapist(70 hours of training) 2000 Licensed Mental Health Counselor(LMHC) State of Florida (License# MH5974) 2000 Certified Trainer for the Iowa Strengthening Families Program: For Parents and Youth 10-14 2000 Certified as an Official FARS and CFARS Rater 1 WORK EXPERIENCE 2013 Licensed Clinical Psychologist Orlandini Psychological Group Provide psychotherapeutic services in English and Spanish to individuals, couples, families and groups treating a wide range of issues. Specialties include Cognitive Behavior Therapy(CBT), hypnotherapy, stress management, emotional dysregulation, depression, anxiety, marital/partner/family therapy and GLBT issues. 2007 -2013 Vice-President of Behavioral Health Miami Beach Community Health Center, Inc. Resigned my position to work in private practice. Performed administrative duties including but not limited to coordination of all behavioral health services, monitoring of census, establishing community ties, developing grants, providing community education on mental health issues,developing healthcare plan goals and objectives, supervising the department/clinicians, and conducting monthly staff meetings and trainings. Also provided outpatient psychotherapy and monitored compliance. Acted as member of the Executive Total Quality Management Committee, Directors Committee, Senior Providers Committee, Re-engineering Committee, Infection Control Committee, Electronic Health Record Committee, Compliance Committee, Credentialing Committee and Patient Care and Safety Committee. 2007 Resigned my position as a Licensed Mental Health Counselor at Citrus Health Network to dedicate myself to preparing for and passing the EPPP exam in Professional Practice of Psychology and the Florida Laws and Rules Exam. 2006-2006 Licensed Mental Health Counselor Citrus Mental Health Network Children and Adolescent Treatment Center(CATS) Worked as part of an inter-disciplinary team providing consultation and psychotherapeutic services in English and Spanish to adolescent clients who have had substance abuse issues, sexual abuse, prostitution, engaged in self- injurious behavior, hostile and aggressive acts out of proportion with the situation, a pattern of risk taking activities, and past elopements from different therapeutic programs. Also attended Miami-Dade County and Broward County Courts with the clients to provide the courts with written and verbal feedback on client motivation, progress, and obstacles to a successful therapeutic outcome. Was an active participant in weekly rounds with the inter-disciplinary team where aspects of client care were addressed. Other services provided were crisis management as well as monitoring the restraining of the clients when they posed a danger to themselves or others and were unresponsive to professional therapeutic de-escalation techniques. Also monitored, when necessary, the administration of intra muscular injection prescribed by staff psychiatrist to decrease the client's agitation and decrease risk of harm to self or others. Provided staff training on improving compliance and communication with the clients to decrease the incidence of 2 escalating behavior. Provided a training seminar at Citrus Health Network on Psychological Treatment of Terminal Ill Patients. 2004 —2006 Post-Doctoral Psychology Fellow University of Miami Jackson Memorial Hospital Sylvester Comprehensive Cancer Center Conducted in-patient consultations, evaluations, as well as provided out- patient psychotherapy. Performed Bone Marrow Transplant Evaluations, Pain Evaluations and worked as part of the Kessenich Family ALS, MDA interdisciplinary team. 2002—2004 Licensed Mental Health Counselor in Private Practice Provided psychotherapy and crisis intervention to individuals, families and children. Specialize in mood disorders and ADHD. Services provided in English and Spanish. 2002-2003 Psychotherapist Hurwitz Child Crisis Nursery Provided group and individual counseling to children with a history of abuse and neglect that had been removed from their homes by DCF. 2001 —2002 Chief Post-Doctoral Psychology Fellow University of Miami/Jackson Memorial Hospital Sylvester Comprehensive Cancer Center Worked as part of an inter-disciplinary team providing consultation and psychotherapeutic services in English and Spanish to Oncology in-patients and out-patients. Provided diagnostic and psychotherapeutic services on a weekly basis to general internal medicine out-patients. The Courtelis Center also provides services to non-medical patients requesting psychotherapy. Facilitated monthly relaxation training groups to Oncology patients and their families. Attended weekly psychiatric grand rounds and participated in in- patient rounds. Provided an in-service on relaxation training for CEU's. Also performed administrative duties as Chief Fellow. 2000—2001 Psychotherapist Citrus Health Network(CHN) Worked as part of an inter-disciplinary team in the Partial Hospitalization Program (PHP) and the Outpatient Program. Performed intake interviews, admissions assessments, psychosocials, formulated treatment plans, and made appropriate referrals. Provided individual, family, and group therapy as well as crisis intervention to individuals with a variety of disorders, including physical health issues. Additionally, worked in the Children's Substance Abuse Prevention Program(CSAPP) providing intensive therapeutic on site services including individual and family therapy in the client's homes. Performed substance abuse psychosocial assessments, formulated treatment plans, quarterly reviews, CFARS Outcome Measures, ASAMs, SISARs,and center wide and program discharge summaries as per Medicaid guidelines. Provided verbal and written progress summaries when necessary to the Miami-Dade County Court, Substituted for program directors due to vacations 3 for one week in CSAPP,two weeks in the PHP, and two weeks in the outpatient assessment unit. Also conducted utilization review and provided certification training on a module of the Iowa Strengthening Families Program. 1998 — 1999 Psychology Intern Miami Dade Office of Youth and family Development Early Intervention Development Center (EIDQ Worked as part of an inter-disciplinary team serving a population consisting of severely emotionally disturbed children and their families. Performed intake interviews, psychosocial assessments, formulated treatment plans and composed weekly rehab summaries as well as quarterly reviews of client progress compliant with Medicaid guidelines. Provided updates to the respective guardian agencies as well as written reports on client progress when necessary. Psychological assessments were also performed. Provided individual, marriage, family, and group therapy as well as crisis intervention and case management. 1998 Research Assistant University of Miami/Jackson Memorial Hospital SMART/EST Women's Project Provided group therapy to a female HIV positive population. Worked as part of the Cultural Linguistics Working Group back translating assessment measures. Provided initial recruitment coordination services for the Spanish portion of the project. Also performed data entry services and participated in weekly research meetings 1996- 1998 Consultant and Therapist Greater Miami Adult Day Center Performed initial assessments, formulated treatment plans, provided individual counseling, and facilitated groups for patients whose health issues exacerbated their psychiatric illness. Was also responsible for providing private individual and family counseling on a self-pay basis under the supervision of a Licensed Mental Health Counselor. 1995- 1997 Substitute Teacher Dade County Puhlic School Board Certified in Psychology, English, and Sociology 1995 Independent Support Coordinator Choices in Support and Services, Inc. Provided individual and family therapy, case management, and organized and formulated support plans and cost plans for a developmentally disabled population. 1995 Psychotherapist Parkday Center at Parkway Hospital Provided group counseling services. 4 1994 Psychotherapist Various Adult Congregate Living Facilities Provided group and individual counseling as well as developing and implementing specific therapeutic interventions. 1994 Psychotherapist Southern Winds Psychiatric Hospital Provided group counseling services as part of a multi-disciplinary team. Developed and implemented a variety of group topics. PRACTICUM EXPERIENCE 1997 - 1998 Practicum Student University of Miami/Jackson Memorial Hospital Provided consultation liaison services to HIV positive individuals and their families. Also performed neuropsychological testing on pre and post kidney and heart transplant patients at the Biobehavioral Medicine Division. Individual counseling was provided on an as needed basis. 1996— 1997 Therapist Mental Health Association Provided individual and family counseling, developed treatment plans and performed psychological testing on a homeless population. 1995 Therapist Goodman Psychological Services Center Performed intake assessments, psychosocial, and developed treatment plans. Provided individual, family, and couples therapy. 1994 Primary Counselor Juvenile Diversionary Program Performed intake assessments, psychosocials, and formulated treatment plans. Provided individual, family and marriage counseling,crisis intervention,and case management to first tine adolescent offenders and their families. 1994 Therapist Charter Hospital of Miami Performed psychosocial assessments, psychosocial addendums, formulated treatment plans, and facilitated and co-facilitated groups. Individual therapy was also provided. 5 RESEARCH 1990 - 1991 Research Assistant University of Miami Childhood Mobility Project Performed structured interviews, administered and scored personality tests, and provided data entry services. VOLUNTEER WOORK 1998 Volunteer Worker University of Mianu/Jackson Memorial Hospital Torture Pilot Study Perfonned back translation services on assessment measures. MEMBERSHIPS 2007 - Present Member of the Douglas Gardens Board of Directors 1999—Present American Psychological Association member 1994—Present PsiChi member in good standing(Psychology Honors Society) LANGUAGES Fluent in English and Spanish 6 i Maria M. Zayas-Bazan, LMHC, Psy.D. 1111 Lincoln Road, Suite 400 Miami Beach, Fl 33129 (305) 815-5903 EDUCATION 2001 Doctor of Psychology Carlos Albizu University Miami Campus 1994 Master of Science in Psychology Miami Institute of Psychology Caribbean Center for Advanced Studies Graduated with Utmost Distinction 1993 Bachelor of Arts in Psychology University of Miami 1989 Associate of Arts in Psychology Miami Dade Community College, North Campus LICENSURE/CERTIFICATION 2007 Licensed Psychologist in the state of Florida(License# PY7521) 2003 Hypnotherapist(70 hours of training) 2000 Licensed Mental Health Counselor(LMHC) State of Florida (License# MH5974) 2000 Certified Trainer for the Iowa Strengthening Families Program: For Parents and Youth 10-14 2000 Certified as an Official FARS and CFARS Rater 1 i \1 WORK EXPERIENCE 2013 Licensed Clinical Psychologist Orlandini Psychological Group Provide psychotherapeutic services in English and Spanish to individuals, couples, families and groups treating a wide range of issues. Specialties include Cognitive Behavior Therapy(CBT),hypnotherapy, stress management, emotional dysregulation,depression, anxiety, marital/partner/family therapy and GLBT issues. 2007 - 2013 Vice-President of Behavioral Health Miami Beach Community Health Center, Inc. Resigned my position to work in private practice. Performed administrative duties including but not limited to coordination of all behavioral health services, monitoring of census, establishing community ties, developing grants, providing community education on mental health issues,developing healthcare plan goals and objectives, supervising the department/clinicians, and conducting monthly staff meetings and trainings. Also provided outpatient psychotherapy and monitored compliance. Acted as member of the Executive Total Quality Management Committee, Directors Committee, Senior Providers Committee, Re-engineering Committee, Infection Control Committee, Electronic Health Record Committee, Compliance Committee, Credentialing Committee and Patient Care and Safety Committee. 2007 Resigned my position as a Licensed Mental Health Counselor at Citrus Health Network to dedicate myself to preparing for and passing the EPPP exam in Professional Practice of Psychology and the Florida Laws and Rules Exam. 2006-2006 Licensed Mental Health Counselor Citrus Mental Health Network Children and Adolescent Treatment Center (CATS) Worked as part of an inter-disciplinary team providing consultation and psychotherapeutic services in English and Spanish to adolescent clients who have had substance abuse issues, sexual abuse, prostitution, engaged in self- injurious behavior, hostile and aggressive acts out of proportion with the situation, a pattern of risk taking activities, and past elopements from different therapeutic programs. Also attended Miami-Dade County and Broward County Courts with the clients to provide the courts with written and verbal feedback on client motivation, progress, and obstacles to a successful therapeutic outcome. Was an active participant in weekly rounds with the inter-disciplinary team where aspects of client care were addressed. Other services provided were crisis management as well as monitoring the restraining of the clients when they posed a danger to themselves or others and were unresponsive to professional therapeutic de-escalation techniques. Also monitored, when necessary, the administration of intra muscular injection prescribed by staff psychiatrist to decrease the client's agitation and decrease risk of harm to self or others. Provided staff training on improving compliance and communication with the clients to decrease the incidence of 2 escalating behavior. Provided a training seminar at Citrus Health Network on Psychological Treatment of Terminal III Patients. 2004—2006 Post-Doctoral Psychology Fellow University of Miami Jackson Memorial Hospital Sylvester Comprehensive Cancer Center Conducted in-patient consultations,evaluations, as well as provided out- patient psychotherapy. Performed Bone Marrow Transplant Evaluations, Pain Evaluations and worked as part of the Kessenich Family ALS, MDA interdisciplinary team. 2002—2004 Licensed Mental Health Counselor in Private Practice Provided psychotherapy and crisis intervention to individuals, families and children. Specialize in mood disorders and ADHD. Services provided in English and Spanish. 2002-2003 Psychotherapist Hurwitz Child Crisis Nursery Provided group and individual counseling to children with a history of abuse and neglect that had been removed from their homes by DCF. 2001 —2002 Chief Post-Doctoral Psychology Fellow University of Miami/Jackson Memorial Hospital Sylvester Comprehensive Cancer Center Worked as part of an inter-disciplinary team providing consultation and psychotherapeutic services in English and Spanish to Oncology in-patients and out-patients. Provided diagnostic and psychotherapeutic services on a weekly basis to general internal medicine out-patients. The Courtelis Center also provides services to non-medical patients requesting psychotherapy. Facilitated monthly relaxation training groups to Oncology patients and their families. Attended weekly psychiatric grand rounds and participated in in- patient rounds. Provided an in-service on relaxation training for CEU's. Also performed administrative duties as Chief Fellow. 2000—2001 Psychotherapist Citrus Health Network(CHN) Worked as part of an inter-disciplinary team in the Partial Hospitalization Program (PHP) and the Outpatient Program. Performed intake interviews, admissions assessments, psychosocials, formulated treatment plans, and made appropriate referrals. Provided individual, family, and group therapy as well as crisis intervention to individuals with a variety of disorders, including physical health issues. Additionally, worked in the Children's Substance Abuse Prevention Program(CSAPP) providing intensive therapeutic on site services including individual and family therapy in the client's homes. Performed substance abuse psychosocial assessments, formulated treatment plans, quarterly reviews, CFARS Outcome Measures, ASAMs, SISARs, and center wide and program discharge summaries as per Medicaid guidelines. Provided verbal and written progress summaries when necessary to the Miami-Dade County Court, Substituted for program directors due to vacations 3 for one week in CSAPP, two weeks in the PHP, and two weeks in the outpatient assessment unit. Also conducted utilization review and provided certification training on a module of the Iowa Strengthening Families Program. 1998 — 1999 Psychology Intern Miami Dade Office of Youth and family Development Early Intervention Development Center (EIDQ Worked as part of an inter-disciplinary team serving a population consisting of severely emotionally disturbed children and their families. Performed intake interviews, psychosocial assessments, formulated treatment plans and composed weekly rehab summaries as well as quarterly reviews of client progress compliant with Medicaid guidelines. Provided updates to the respective guardian agencies as well as written reports on client progress when necessary. Psychological assessments were also performed. Provided individual, marriage, family, and group therapy as well as crisis intervention and case management. 1998 Research Assistant University of Miami/Jackson Memorial Hospital SMART/EST Women's Project Provided group therapy to a female HIV positive population. Worked as part of the Cultural Linguistics Working Group back translating assessment measures. Provided initial recruitment coordination services for the Spanish portion of the project. Also performed data entry services and participated in weekly research meetings 1996— 1998 Consultant and Therapist Greater Miami Adult Day Center Performed initial assessments, formulated treatment plans, provided individual counseling, and facilitated groups for patients whose health issues exacerbated their psychiatric illness. Was also responsible for providing private individual and family counseling on a self-pay basis under the supervision of a Licensed Mental Health Counselor. 1995— 1997 Substitute Teacher Dade County Public School Board Certified in Psychology, English, and Sociology 1995 Independent Support Coordinator Choices in Support and Services, Inc. Provided individual and family therapy, case management, and organized and formulated support plans and cost plans for a developmentally disabled population. 1995 Psychotherapist Parkday Center at Parkway Hospital Provided group counseling services. 4 1994 Psychotherapist Various Adult Congregate Living Facilities Provided group and individual counseling as well as developing and implementing specific therapeutic interventions. 1994 Psychotherapist Southern Winds Psychiatric Hospital Provided group counseling services as part of a multi-disciplinary team. Developed and implemented a variety of group topics. PRACTICUM EXPERIENCE 1997 - 1998 Practicum Student University of Miami/Jackson Memorial Hospital Provided consultation liaison services to HIV positive individuals and their families. Also performed neuropsychological testing on pre and post kidney and heart transplant patients at the Biobehavioral Medicine Division. Individual counseling was provided on an as needed basis. 1996- 1997 Therapist Mental Health Association Provided individual and family counseling, developed treatment plans and performed psychological testing on a homeless population. 1995 Therapist Goodman Psychological Services Center Performed intake assessments, psychosocial, and developed treatment plans. Provided individual, family, and couples therapy. 1994 Primary Counselor Juvenile Diversionary Program Performed intake assessments, psychosocials, and formulated treatment plans. Provided individual, family and marriage counseling, crisis intervention, and case management to first tine adolescent offenders and their families. 1994 Therapist Charter Hospital of Miami Performed psychosocial assessments, psychosocial addendums, formulated treatment plans, and facilitated and co-facilitated groups. Individual therapy was also provided. 5 RESEARCH 1990 - 1991 Research Assistant University of Miami Childhood Mobility Project Performed structured interviews, administered and scored personality tests, and provided data entry services. VOLUNTEER WOORK 1998 Volunteer Worker University of Miami/Jackson Memorial Hospital Torture Pilot Study Performed back translation services on assessment measures. MEMBERSHIPS 2007 - Present Member of the Douglas Gardens Board of Directors 1999—Present American Psychological Association member 1994—Present PsiChi member in good standing(Psychology Honors Society) LANGUAGES Fluent in English and Spanish 6