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Alcohol and Drug Abuse Division (Hawaii)

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ADAD CSAC Application I July 2020 1
Alcohol and Drug Abuse Division
(ADAD)
CSAC A
PPLICATION
Certified Substance Abuse Counselor
§11-1
77.1 “Substance abuse counselor” means a person who through both education and
demonstrated experience, is capable of providing the twelve-core functions and, at a minimum,
directly provides assessment, treatment planning and implementation, counseling, and
discharge planning, as they relate to substance abuse treatment. Substance abuse counselor is
synonymous with alcohol and drug counselor and chemical dependency counselor.
601 Kamokila Blvd. #360, Kapolei, HI 96707
Phone: 808-692-7506 Fax: 808-692-7521
https://health.hawaii.gov/substance-abuse/
https://health.hawaii.gov/substance-abuse/counselor-certification/
2
Pr
Prior to submitting your application, review all the requirements and download the application.
Use the table below as a guide for gathering your documents.
Do not submit any documentation with your application that is not listed on the table or the
application unless instructed by ADAD.
TO SUBMIT YOUR APPLICATION, MAIL TO:
ADAD: Quality Assurance and Improvement Office
601 Kamokila Blvd. #360
Kapolei, HI 96707
INQUIRES CONTACT:
Angela Bolan
Phone: 808-692-7521
angela.bolan@doh.hawaii.gov
ADAD CSAC Application I July 2020
REQUIREMENT
DOCUMENT
Application with Payment
Certified cashier’s check or money order made
payable to “State Director of Finance”/no credit
card, personal checks or cash accepted
Code of Ethics
Signature Required pg. 10
Initial Release Formhttps://health.hawaii.gov/substance-
abuse/files/2019/12/Code-of-Ethics-CSAC-CCS-CCJP-
CSAPA.pdf
Current Job Description
Obtain from employer submit with application
Disciplinary Actions (if applicable)
Include letter of explanation with application
Copy of Photo ID
Include with application
Legal/Civil Convictions (if applicable)
Include letter/legal documents with application
Work Experience / Internship/Practicum
Obtain from and employer who meets the requirements
Education
Official transcripts sent directly to the ADAD, when file is open
Code of Ethics
Retain for your records
Twelve Code Functions
Retain for your records
Hawaii Administrative Rules 11.177.1
Retain for your records
Schedule for an Orientation Meeting
You will be notified with available dates
APPLICATION INSTRUCTIONS – READ CAREFULLY
ADAD CSAC Application I July 2020 3
REVIEW, APPROVAL, & PROCESS
1. Application submitted to ADAD. To request receipt confirmation of your application, email
ADAD attention: Carrie at carrie.figueiroa@doh.hawaii.gov
2. ADAD reviews application. Allow 6-8 weeks for review and processing of your application.
3. Applicant will be emailed if there is any documentation missing from the application or there
are questions regarding your application. It is imperative to provide your email and contact
phone number.
4. Your application is considered approved when you receive an email that your file has been
opened. You will also need to attend an orientation meeting. Your file will open for a
minimum of seven (7) years from the time of application with activity. If your file is inactive for
two (2) years, ADAD will make one attempt to contact you. If no response by five (5) business
days, ADAD will close your file.
5. When your file is open, all other documents must be sent to ADAD (via mail). Documents
sent through email will NOT be accepted unless specifically instructed to do so.
6. Review of education and work verification takes up to 4-6 weeks.
7. Once all requirements are met, ADAD will send you the examination application.
8. Upon receiving your exam application and payment, ADAD will preregister you for the exam.
9. Follow all instructions that will be emailed to scheduling your exam.
10. Once you pass the exam, ADAD will notify you and verify your certificate information (via
email), within 30 days.
11. Your official certificate will arrive in the mail within 5-10 business days upon receiving your
verification email.
ADAD CSAC Application I July 2020 4
CERTIFICATION REQUIREMENTS
*eligible for reciprocity and international certification to include over sight of the 12-core functions
Certification
Education
Hours
Supervised
Work
Verification
12- Core
Functions
Required
Education
6 hours in each
Requirement
*CSAC
High School
Diploma/Equivalent
300
270 SUD
specific
6000
(400 of which is
in the 12-Core
Functions)
400
(20 minimum
in each core)
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
*CSAC with
Bachelors in BH
Or Certificate in
SUD education
300
270 SUD
specific
4000
(400 of which is
in the 12-Core
Functions)
400
(20 minimum
in each core)
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
*CSAC with
Masters in BH
300
270 SUD
specific
2000
(400 of which is
in the 12-Core
Functions)
400
(20 minimum
in each core)
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
*CSAC Licensed
Physician
(Specialty)
Physician certified
by the American
Society of
Addiction Medicine
or Board-Certified
Psychiatry by
American Board of
Psychiatry and
Neurology
license to
practice in the
State of Hawaii
CSAC Licensed
Physician (General)
50
SUD specific
education
1000
Direct SUD
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
license to
practice in the
State of Hawaii
Exam Required
APPLICATION INFORMATION
ADAD CSAC Application I December 2019 5
DEGREE/EDUCATION/TRAINING
The degree must be from an accredited college/university that the US Department of Education
of from the Council on Higher Education/Accreditation approves. An official transcript sent
directly from college/university is required. If the degree is from outside the United States a
degree equivalency must done by an organization that specializes in that process. The applicant
is responsible for arranging this process and all cost. Photocopies and student copies will not be
accepted.
Degree obtained must be relevant to the field to be applicable.
Education certificates/training must be approved by ADAD. Exceptions for continuing education
are already pre-approved by the National Association of Social Workers (NASW), the American
Psychological
Association (APA), the American Medical Association (AMA), and the National Board of Certified
Counselors (NBCC)
The courses must be at least one (1) hour in length per covered subject. Most three-credit
college/university course are 45 hours. For initial certification: the courses must be directly
Certification
Eligibility
Education
Hours
Supervised
Work
Verification
12- Core
Functions
Required
Education
6 hours in each
Requirement
CSAC Licensed
psychologist
(specialty)
With a certificate of
proficiency in
alcohol and other
psychoactive
substance used
disorders from APA
license to
practice in the
State of Hawaii
Exam Required
and proficiency
certificate
CSAC licensed
psychologist
(General)
50
SUD specific
education
1000
Direct SUD
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
license to
practice in the
State of Hawaii
Exam Required
CSAC Licensed
Clinical SW, LMFT,
LMH
100
SUD specific
education
1000
Direct SUD
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
license to
practice in the
State of Hawaii
Exam Required
CSAC Advance
Practice Registered
nurse
100
SUD specific
education
1000
Direct SUD
HIV& STD
SUD Ethics
Confidentiality
to include 42
CFR Part 2
license to
practice in the
State of Hawaii
Exam Required
ADAD CSAC Application I December 2019 6
related to the eight domains of clinical evaluation, treatment planning, referral, service
coordination, counseling, client, family and community education, documentation, and
professional and ethical responsibility as pertain to substance use disorder functions.
ADAD may take up to 180 educational hours from transcripts relevant to the field of substance
use disorder and up to an additional 45 total with co-occurring disorder.
Education accomplished through workshops approved by ADAD for continuing education or
through ADAD-approved distance learning must be documented by submitting a copy of the
certificate of completion to include hours. Distance learning is limited to 50% (135 hours) of the
total education required unless authorized by the division.
A minimum of six (6) hours of education is required three areas:
1. Substance Use Disorder Ethics,
2. Title 42 Code of Federal Regulations, part 2 and HIPAA (Health Insurance Portability and
Accountability Act)
3. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS).
CURRENT JOB DESCRIPTION
All applicants must include their current job description with their application. This document is
provided by your employer and must be signed and dated by you and your supervisor. Job
descriptions are reviewed as a part of experience verification. If your supervisor does not have
your job description, you should contact your organization’s Human Resource department.
LEGAL/ CIVIL CONVICTIONS AND DISCIPLNARY ACTIONS
A background check is done on all applicants. If there are any legal/civil convictions, disciplinary
actions from other certification/licensing entities, documentation is required at the time of the
application. An application may be refused due to a conviction for a crime when the crime
directly relates to the applicant’s possible performance as a substance abuse counselor.
EXPERIENCE AND SUPERVISON
Qualifying experience is defined as providing primary, direct, and/or clinical, substance use
disorder counseling to persons whose primary diagnosis is that of substance use disorder.
Applicant must have primary responsibility of providing substance use disorder counseling in an
individual and/or group setting, preparing treatment plans, documenting client progress and
clinical supervise clients. Examples of positions that typically are not approved include: case
managers, technicians, peer and recovery counselors, etc.
The applicant must be currently employed in the qualifying position at the time of application.
Only employment within the last seven (7) years may be counted towards the total experience
requirement.
ADAD CSAC Application I July 2020 7
If the applicant’s experience requirement is not fulfilled from their current employer, they must
include a letter (on company letterhead) from previous employer(s) verifying their duties and
dates of employment and use the appropriate work verification provided by the department.
The supervisor must be employed or contracted by the program or agency in which the work
experience is gained.
Those who do require the Twelve (12) Core Functions shall document on a form provided by
the department four hundred hours (400) of supervised practical training. Four hundred (400)
hours shall be completed under the supervision of a certified substance abuse counselor in a
category which is eligible for reciprocity.
FEES
The application fee may be paid by money order or Cashier’s check payable to:
The State Director of Finance
ADAD shall collect a non-refundable fee for each of the following:
Initial application $25.00
Renewal Fee $25.00
Examination Fee& Retesting $150.00 (missed testing fee is the sole responsibility
of the candidate)
EXAMINATION
Applicants must pass the IC&RC Examination
Domains:
1. Screening, Assessment, & Engagement
2. Treatment Planning, Collaboration, & Referral
3. Counseling & Education
4. Professional & Ethical Responsibilities
The examination is a computer based, 150 multiple-choice questions and offered an on-
demand basis at an approved testing site. Candidates may choose the day, time, and site. There
are limited sites in state, so travel may be necessary. The applicant is responsible for arranging
this process and all cost.
Time Permitted: 3 hours to complete the exam.
Study Material: Visit IC&RC website for more information: www.internationalcredentialing.org
Special Situations & Accommodations
EXAMINATION INFORMATION
ADAD CSAC Application I July 2020 8
Individuals with disabilities that require modifications in examination administration may
request specific procedure changes in writing with the official documentation to ADAD no
fewer than 60 days prior to their examination date. Contact ADAD on what constitutes official
documentation. ADAD will plan for appropriate modifications to its procedures when
documentation supports the need.
PASSING
If the applicant passes the examination and has met all the requirements of certification, an
ADAD staff will notify you and verify your certificate information (via email), within 30 days.
Your official certificate will arrive in the mail within 5-10 business days upon receiving your
verification email. Certification shall be granted for a period of two (2) years.
Cancellation/Reschedule
Candidates are required to arrive on time for their exam. Candidates who arrive late will not be
permitted to take the examination and will be charged a $150.00 cancelation/rescheduling fee.
RETESTING
Candidates who fail the examination can retest after a 90 day wait period from the date of their
last exam. Candidates will be sent instructions and fee information. Candidates have three
opportunities to retake an examination. Candidate who fails the examination three (3)
consecutive times must obtain 480 additional hours of clinically supervised work experience
and possibly further education, including the possibility of additional meeting with ADAD and
the candidate’s mentor, before applying to retake the examination.
ADAD CSAC Application I July 2020 9
First Name,
Middle
Initial:
Last
Name:
Previous
Names:
DOB:
SSN:
Home
Address
City:
State:
Zip:
Island:
Email:
Alternative
Email:
Phone #:
Other
Phone#
Gender:
Legal/Civil/Disciplinary Action(s):
Yes
If yes is indicated on the Legal/Civil/Disciplinary Actions, please send in documentation as indicated
Ethnicity
☐
Alaskan Native
☐
American Indian
☐
Cambodian
☐
Chinese
☐
Filipino
☐
Japanese
☐Korean ☐Laotian ☐ Okinawan ☐Other Asian ☐Fijian ☐Hawaiian ☐ Part Hawaiian
☐ Micronesian Samoan ☐Tongan ☐ Other Pacific Isle
☐African American ☐Caucasian ☐ Portuguese ☐Cuban ☐Mexican
☐Puerto Rican ☐Other Hispanic ☐ Mixed, ☐Other, specify Click or tap here to enter
text.
Languages
Please indicate other language (s) fluent in other than English
Current
Employment
Employer Name:
Contact Number:
Address:
Email:
Applicant Position/Title:
Hire Date in Current Position:
How many hours do you work per week?
Current
Supervisors
Information
Immediate Supervisor:
Supervisor Position/Title:
Email:
Phone:
CERTIFIED SUBSTANCE ABUSE COUNSELOR
Highest Level of Education Completed:
Name on Transcript:
This page must be completed by the applicant. It must be submitted with the application.
I am applying for a CSAC with
HS Diploma
Certificate in SUD/Bachelors/Masters
License SW,
MFT, MH
License
Physician, Psychologist/Psychiatrist/APR
RELEASE
I request that the Alcohol and Drug Abuse Division (ADAD) grant the credential to me based on
the following assurance and documentation:
• I subscribe to and commit myself to professional conduct in keeping with the CSAC Code
of Ethics; Sign Here as Acknowledgment of the Code of Ethics :
________________________________ Date:___________________
• I certify that the information given herein is true and complete to the best of my
knowledge and belief. I also authorize any necessary investigation and the release of
information relative to my credential. Falsification of any documents will nullify this
application and will result in denial or revocation of certification;
• I consent to the release of information contain in my application and other pertinent
date submitted to or collect by ADAD;
• I consent to authorize ADAD to gather information form third parties regarding
education and employment and understand that such communication shall be treated as
confidential;
• Allegations of ethical misconduct reported to ADAD before, during, or after application
for certification is made will be investigated by ADAD and could result in nullification of
the application or denial or revocation of the certification.
Initial Each Statement
I have read and understood the Release
I either live or work in the State of Hawaii at least 51% of the time
I understand the application fee in nonrefundable if application is denied or
cancelled prior to the examination and no refund will be issued if application is
denied or called after examination
I understand that my application is open for a period of seven (7) years after the date
of review, providing there is activity towards progression and/or two (2) years with
no activity. If no activity is done within in 2 (two) years my file will be closed.
I understand that it is my responsibility to work with my supervisor on work
verification hours.
I understand if my current job changes, I need to submit a new job description.
I understand that if I have a new supervisor, the supervisors job description needs to
be submitted.
Applicant Signature:
ADAD CSAC Application I Revised July 2020 10
Date:
Administrative Only:
Fee Received: _________ Background check__________
Ethics________ Transcript______ Resume___________
Resume________ Job description________ ID_________
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Completed 13 March 2021

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