Fillable Application For Licensure Or Certification As An Alcohol And Drug Counselor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application For Licensure Or Certification As An Alcohol And Drug Counselor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Application For Licensure Or Certification As An Alcohol And Drug Counselor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 35 pages long and contains:

  • 14 signatures
  • 110 check-boxes
  • 741 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
124 Halsey Street, 6th Floor, P.O. Box 45040
Newark, New Jersey 07101
(973) 504-6582
Application for Licensure as a Clinical Alcohol and Drug Counselor or
Certication as an Alcohol and Drug Counselor
Date:
A nonrefundable application ling fee of $75, in the form of a check or money order made out to the State of New Jersey, must be
submitted with this application. (Applicants should understand that if the application ling fee is paid with a personal check, and the check
is returned by the bank due to insufcient funds, the next step in the licensure or certication process will be delayed until the fee is paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State Country
Attach two, full-face passport-
style photographs (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
Two photographs are required
with each application.
Do not use staples to attach the
photographs.
Written Examination
Oral Examination
Written and Oral Examinations
________________
Date exam passed
Certied Alcohol and
Drug Counselor (C.A.D.C.)
Licensed Clinical
Alcohol and Drug
Counselor (L.C.A.D.C.)
Licensure by Reciprocity
Please check if you are applying for:
Mr.
1. Name Mrs. ____________________________________________________________ (______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: _________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
____________________________________ _________________________________
Telephone number (include area code) E-mail address
Business: _______________________________________________________________________________________
Name of company Telephone number (include area code)
________________________________________________________________________________________
Street City State ZIP code County
Mailing: ________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
- 1 -
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding?
Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of your licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
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7. Have you previously applied for a license or certicate as an Alcohol and Drug Counselor in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
If “Yes,” when? ________________________________________
8. Have you ever passed an oral and/or written alcohol and drug counseling examination in New Jersey, any other state, the District of
columbia or in any other jurisdiction? Yes No
If “Yes,” please attach a copy of your examination scores to this application.
9. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
10. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
11. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expire
12. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction?
Yes No
13. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
14. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any
agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. Have you ever been named as a defendant in any litigation related to the practice of alcohol and drug counseling or other
professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
17. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
18. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of alcohol and drug counseling or other professional practice in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 4 -
Education
1. What is the name and address of the high school you attended? _____________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State /Country ZIP code
2. What years did you attend high school? _____________________
3. Did you graduate from high school? Yes No
If “Yes,” what was the date of your graduation? ______________________________
Month Year
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date certicate was issued
4. What is the name and address of the colleges or universities you have attended?
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
5. List all of the degrees that you have received from recognized colleges or universities. Please have each college or university forward
to the Committee the ofcial transcript for each degree that you have earned. (See page 7.)
Educational institution Inclusive years Title of Degree, Major Date granted
Diploma or
Certicate
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
a)
b)
c)
d)
- 5 -
Graduate Level Academic Course Work for L.C.A.D.C.
(You should supply the information on this page only if you are applying for recognition as a Licensed Clinical Alcohol and Drug
Counselor.)
As set forth in the regulations, the graduate semester hours in course work will include graduate semester hours received in the following
areas. Please list which courses indicated on your transcript(s) satisfy the relevant areas. Only graduate courses should be listed, not
undergraduate course work. If you were enrolled in a combined bachelor’s/master’s program, only the master’s level course work will
be accepted. Doctoral course work may also be accepted. Each course may be listed only once.
- 6 -
Area Course title and Hours College/University
Course number
(Indicate semester hours)
Counseling theory a. _________________________ ___________ _____________________
and practice. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
The helping a. _________________________ ___________ _____________________
relationship. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
Human growth and a. _________________________ ___________ _____________________
development, and b. _________________________ ___________ _____________________
maladaptive behavior. c. _________________________ ___________ _____________________
Lifestyle and career a. _________________________ ___________ _____________________
development. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
Group dynamics, a. ___________________________ ___________ _______________________
processing, counseling
b. _________________________ ___________ _____________________
and consulting. c. _________________________ ___________ _____________________
Assessment of a. _________________________ ___________ _____________________
individuals. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
Social and cultural a. _________________________ ___________ _____________________
foundations. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
Research and a. _________________________ ___________ _____________________
evaluation. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
The counseling a. _________________________ ___________ _____________________
profession. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
Pharmacology and a. _________________________ ___________ _____________________
Physiology. b. _________________________ ___________ _____________________
c. _________________________ ___________ _____________________
(All applicants must complete and submit Schedules A and B which are included in this application.)
Academic Degree Verication
(Only for Licensed Clinical Alcohol and Drug Counselor Applicants)
Applicant’s name (please print): _____________________________________________________________
Name appearing on transcripts or diplomas (if different from above):
_______________________________________________________________________________________
Social Security number of applicant: _________________________________________________________
College/university ________________________________________________________________________
Degree awarded: _____________________________Major: ______________________________________
Date degree was granted: ______________________
I hereby authorize the college or university above to forward a certied copy of my transcript directly to the:
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
124 Halsey Street, 6th Floor
P.O. Box 45040
Newark, NJ 07101
Note: Applicants should send this form directly to the college/university with the fee required by the college
or university. The application process cannot proceed until we receive the ofcial transcript.
Date : __________________________
Applicant’s name (please print): _____________________________________________________________
Applicant’s signature: _____________________________________________________________________
Applicant’s address _______________________________________________________________________
- 7 -
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AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
In completing this afdavit and application form, I swear (or afrm) that the information provided is true, including all
copied documents to the best of my knowledge and belief. I understand that any omission, inaccuracies, or failure to make
full disclosures may be deemed sufcient to deny licensure or certication or to withhold renewal of or suspend or revoke
a license or certicate issued by the Committee and may subject the applicant to other penalties.
I further swear (or afrm) that I have read N.J.S.A. 45:2D-1 et seq., together with the Rules and Regulations of the Alcohol
and Drug Counselor Committee, N.J.A.C. 13:34C-1 through 6.4, and fully understand that in receiving licensure or certica-
tion from the Committee, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers, agen-
cies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or
records requested by the Committee.
I hereby authorize the Addiction Professionals Certication Board of New Jersey, Inc. or any other state alcohol and drug
certication board, to release to the Alcohol and Drug Counselor Committee and the State Board of Marriage and Family
Therapy Examiners any and all records concerning allegations of ethical or professional violations made against me dur-
ing the period when I was licensed or certied by that body, or whether my licensure or certication has ever been denied,
suspended or revoked.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx Seal Here
} ss.
- 8 -
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Schedule A
Supervisor’s Forms
300 Hours of Supervised Practical Training
If you have been previously certied as an alcohol and drug counselor by an
International Certication Reciprocity Consortium afliated board, you may submit verication
from the Addiction Professionals Certication Board of New Jersey in lieu of completing Schedule A.
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
Supervisor(s) name: __________________________________________________________________________________________
You should send a photocopy of this page to every supervisor and/or agency that provided this training.
(All practicum hours must have been completed within the three-year period immediately preceding the submission of this
application.)
Core functions of alcohol Hours required When completed (month/year) Supervisor’s signature
and drug counseling
1. Screening 15 hours _________________________ ______________________________
2. Intake 15 hours _________________________ ______________________________
3. Orientation 15 hours _________________________ ______________________________
4. Assessment 15 hours _________________________ ______________________________
5. Treatment Planning 35 hours _________________________ ______________________________
6. Individual Counseling 35 hours _________________________ ______________________________
7. Group Counseling 35 hours _________________________ ______________________________
8. Family Counseling 30 hours _________________________ ______________________________
9. Case Management 20 hours _________________________ ______________________________
10. Crisis Intervention 15 hours _________________________ ______________________________
11. Client Education 15 hours _________________________ ______________________________
12. Referral 15 hours _________________________ ______________________________
13. Consultation 15 hours _________________________ ______________________________
14. Reports/Recordkeeping 25 hours _________________________ ______________________________
I hereby certify that the supervised hours listed above were completed as noted.
__________________________________________________ ______________________________________
Applicant’s signature Date
- 9 -
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Documentation of 3,000 Hours of Related Work Experience
Pursuant to N.J.A.C. 13:34C-2.3(b)
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Instructions: This form should be completed if you are applying for licensure as a clinical alcohol and drug counselor or for certication
as an alcohol and drug counselor. You may make photocopies of this page. Your experience must be in a 12-core-function alcohol and
drug treatment position. Experiential hours may go back only ve years.
All positions being documented must be accompanied by:
• an ofcial job description signed by your supervisor and program director
• a program description (brochure or yer) signed by the program director
• each job must include one Supervisor Evaluation Form (included in this application)
• a current resume of your clinical supervisor
• your current resume (as the applicant).
Applicant’s name: ____________________________________________________________________________________________
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Program director: ____________________________________________________________________________________________
Name of supervisor(s): ________________________________________________________________________________________
Your job title: ______________________________________ Dates of employment: _________________ to _________________
Please put a check in the box next to the title of the position you held. Counselor Intern Trainee Volunteer
(Note: The number of hours indicated in the answers to questions number 2 and 3 must equal the total number of hours indicated
in the answer to question number 1.)
1. How many hours of supervised experience in alcohol and drug counseling are you documenting? ___________________________
2. Of the hours documented in question number 1, how many hours in direct (face-to-face) client counseling are you documenting?
__________________________
3. Of the hours documented in question number 1, how many were spent in all other core-function areas? ______________________
__________________________________________________ ______________________________________
Applicant’s signature Date
__________________________________________________
Employer/ Supervisor’s signature
- 10 -
Supervisor Information Form
Please put a check in the box next to the type of application the applicant is submitting.
L.C.A.D.C. application C.A.D.C. application
Note to supervisor: The Alcohol and Drug Counselor Committee of the State Board of Marriage and Family Therapy Examiners believes
that licensure and certication should be based on input from a variety of sources, including the observations of people who supervise the
applicant. For this reason, each applicant is required to obtain an evaluation from a clinical supervisor. Your evaluation, among others, and
data furnished by the applicant will be used in determining eligibility for licensure or certication. As this process can only be effective
with careful and truthful reporting, all information gathered in the evaluation process is condential.
Please return this form and the attached ratings to the address listed on page one. In the event that you cannot rate the applicant on the
items, please indicate so, and return this form to the Committee.
The supervisor must submit a copy of his or her resume or a statement about his or her background with this evaluation.
Applicant’s name: ____________________________________________________________________________________________
Agency’s name: ______________________________________________________________________________________________
Agency’s address: ____________________________________________________________________________________________
Name of supervisor(s): ________________________________________________________________________________________
Title of supervisor(s): ____________________________________ Telephone number (include area code): ____________________
Length of time you have:
A. Known the applicant ________________________________________
B. Provided direct supervision of this applicant _____________________
Please complete:
I hereby certify that I have been in a position to directly supervise the above-named person’s work. In my judgment, this applicant’s
eligibility and professional experience (check one) is is not consistent with licensure or certication standards as set forth by
the Alcohol and Drug Counselor Committee of the State Board of Marriage and Family Therapy Examiners. The information that I am
providing is my best judgment of the above-named person’s capabilities to be: (check one)
licensed as a clinical alcohol and drug counselor, or certied as an alcohol and drug counselor.
The type(s) of supervision I have used with this counselor include those checked below.
Audio/video tapes Case discussions Group supervision One-way mirror observation
Case presentations Individual supervision Telephone consultation Other
__________________________________________________ ______________________________________
Supervisor’s signature Date
Professional licensure, degrees or certications: ____________________________________________________________________
I am a Certied Clinical Supervisor
- 11 -
Supervisor Evaluation Form
Please put a check in the box next to the type of application the applicant is submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
Evaluator’s name: ____________________________________________________________________________________________
Note: Please rate the applicant in each area using the following scale:
0 = No basis for judgment
1 = Inadequate
2 = Needs development
3 = Acceptable
4 = Good
5 = Outstanding
Area of knowledge, skills or competency
1) Communication
a) Oral __________
b) Written __________
2) Knowledge of Alcoholism/Drug Abuse
a) Physiological __________
b) Pharmacological __________
c) Psychological __________
3) Evaluation and Client Assessment
a) Knowledge of:
i) Human growth and development __________
ii) Family dynamics and interaction __________
iii) Signs and symptoms of alcoholism and drug abuse __________
iv) Signs and symptoms indicating referral for medical,
psychological or other assessment __________
b) Analytical skills:
i) Assessing stages of alcoholism/abuse __________
Area of ethical standards
1) Orientation in all efforts towards a primary goal of recovery for the client and his or her family. _________
2) Respect for condentiality of records, materials and communication concerning clients. _________
3) Respect for the client by maintaining an objective, nonpossessive professional relationship. _________
4) No discrimination among clients or professionals on the basis of race, color, creed, age, sex or sexual orientation. _________
5) Respect for the rights and views of other alcohol and/or drug workers and other professionals. _________
6) Respect for institutional policies and cooperation with management functions.
Initiative toward improving institutional policies and management functions. _________
- 12 -
7) Evidence of genuine interest in helping people with alcohol and/or drug problems and dedication to helping
lead clients to methods of helping themselves as much as possible. _________
8) Willingness to access one’s own personal and vocational strengths and limitations, biases and effectiveness.
The ability and willingness to recognize when it is in the client’s best interest to refer or release him or her to
another individual or program. _________
9) Willingness to take personal responsibility for continued professional growth through further education or training. _________
10) Total commitment to providing the highest quality of care through both personal effort and the utilization of any
other health professional or services which may assist the client in his or her recovery program. _________
Certication
I hereby certify that I have provided a minimum of __________ hours of face-to-face clinical supervision per month including
__________ hours of individual supervision and __________ hours of group supervision.
_______________________________________________ ______________________________________
Supervisor’s signature Date
* Additional comments may be made below.*
- 13 -
Self-Help Meeting Verication Form
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
(Specied below are the minimum number of self-help meetings required for this application.)
Minimum Number of Meetings Required:
A.A. - 5 ALANON - 5 N.A. - 5 OTHER - 15
Date A.A. location Date Name of other self-help groups
(Can include additional A.A., ALANON, N.A. groups
or other self-help groups.)
1) __________________ ___________________________ 1) __________________ ________________________________
2) __________________ ___________________________ 2) __________________ ________________________________
3) __________________ ___________________________ 3) __________________ ________________________________
4) __________________ ___________________________ 4) __________________ ________________________________
5) __________________ ___________________________ 5) __________________ ________________________________
__________________ ___________________________ 6) __________________ ________________________________
__________________ ___________________________ 7) __________________ ________________________________
__________________ ___________________________ 8) __________________ ________________________________
__________________ ___________________________ 9) __________________ ________________________________
__________________ ___________________________ 10) __________________ ________________________________
__________________ ___________________________
__________________ ___________________________ 11) __________________ ________________________________
__________________ ___________________________ 12) __________________ ________________________________
__________________ ___________________________ 13) __________________ ________________________________
__________________ ___________________________ 14) __________________ ________________________________
__________________ ___________________________ 15) __________________ ________________________________
Date ALANON location
1) __________________ ___________________________
2) __________________ ___________________________
3) __________________ ___________________________
4) __________________ ___________________________
5) __________________ ___________________________
Date N.A. location
1) __________________ ___________________________
2) __________________ ___________________________
3) __________________ ___________________________
4) __________________ ___________________________
5) __________________ ___________________________
As required for licensure as a clinical alcohol and drug counselor or certication as an alcohol and drug counselor in the State of New
Jersey, I certify that I have attended the meetings listed on this form.
__________________________________________________ ______________________________________
Applicant’s signature Date
As the applicant’s supervisor, I certify that the applicant has provided documentation that he or she has attended the meetings listed
above.
__________________________________________________ ______________________________________
Supervisor’s signature Date
- 14 -
Schedule B
Academic and Professional Training
(This schedule must be completed and accepted prior to
requesting to sit for the exam.)
1. You must attach a copy of your academic degree(s) to this section if the degree is either required or applicable. You must have
sent the “Academic Degree Verication” form (Page 7) to the college/university for all required or applicable degrees.
Yes, I submitted the authorization
No, I had no need to submit the authorization (e.g.: No college experience or if you already hold a New Jersey clinical license)
2. You must complete the following ve pages of Domain-Specic Core Training and attach copies of course completion certicates in
order for the Committee to review your core course work. Certicates must be clearly marked and placed in sequential order (i.e.,
all domains together, all education topics in order, etc.).
3. In lieu of completing Schedule B, you may submit:
Your previous Addiction Professionals Certication Board of New Jersey (APCBNJ)-issued C.A.D.C. certicate, or
Verication of Reciprocity Certication from the International Certication Reciprocity Consortium (ICRC).
4. If you are seeking to apply any of the 270 core-training hours as being completed in your formal academic degree training, you
should do one of the following two procedures:
Submit verication from the college/university that the course work has been pre-approved to fulll the 270 hours of core training
within the academic degree program.
If the college/university has not been pre-approved to provide the 270 hours within the course work, you submit your transcript
and course descriptions to the APCBNJ (APCBNJ is authorized to translate the academic training into the equivalent core-
training hours.) APCBNJ will notify you of any decient core-training hours that are required and/or issue a transcript verifying
the 270-hour equivalent.
5. Written and Oral Examinations
I have not completed the required written and oral examination for certication/licensure as an alcohol and drug counselor.
I have passed an approved written examination for alcohol and drug counseling. (Attach a copy of the examination results
notication.)
I have passed the required oral examination for alcohol and drug counseling. (Attach a copy of the examination results
notication.)
I am exempt from the written and oral examinations for alcohol and drug counseling pursuant to N.J.S.A. 45:2D-4b in that I
hold an active New Jersey clinical license in an appropriate discipline. The license must be appropriate to provide independent
(nonsupervised) practice at the master’s or doctorate level and includes:
Ph.D./Psy.D. - Psychologist
M.D./D.O.
L.C.S.W.
A.P.N.
L.P.C.
L.M.F.T.
Other (Specify) ___________
- 15 -
Schedule B
Academic and Professional Training
(This schedule must be completed and accepted before you sit for the exam.)
Please complete the following pages and submit them with your application or obtain a certied transcript for the ve domains from the
Addiction Professionals Certication Board of New Jersey.
Name: _________________________________________________________________________________
Mailing address: _________________________________________________________________________
Daytime telephone number (include area code) _________________________________________________
1. You must attach a copy of your degree(s), if applicable.
2. You must attach copies of course certicates in order for the Committee to review your course work.
3. Course certicates must be clearly marked and placed in sequential order (i.e., all domains together, all education topics in
order, etc.).
4. In lieu of completing Schedule B, you may submit a copy of your current Certied Alcohol and Drug Counselor certicate or an
ofcial transcript from the Addiction Professionals Certication Board of New Jersey (APCBNJ). You must complete this rst
page.
5. If you have been previously certied as an alcohol and drug counselor by an ICRC afliated board, you may submit verication
from the APCBNJ in lieu of completing Schedule B of this form.
6. If you are using academic course work, you must also submit verication from the APCBNJ or the academic institution that the
course work was pre-approved as initial core training. If you are not sure if it has been pre-approved, please contact the
APCBNJ for verication. If it has not been pre-approved, the APCBNJ can approve core content areas in the academic course work
after the fact.
7. If you have already completed an approved written and/or oral addiction counseling examination, attach copies of the ofcial
notication of examination results, as applicable.
Required Core Course Work is as follows:
Course Work Domain I- Course Work Domain IV-
Initial Interviewing Process Addiction Recovery
Biopsychosocial Assessment Psychological Client Education
Differential Diagnosis Biochemical/Medical Client Education
Pharmacology-Physiology of Substance Abuse Sociocultural Client Education
Diagnostic Summaries Addiction Recovery and Psychological Family Education
Compulsive Gambling Biomedical and Sociocultural Family Education
Community and Professional Education
Course Work Domain II- Course Work Domain V-
Introduction to Counseling Ethical Standards
Introduction to Techniques and Approaches Legal Aspects
Crisis Intervention Cultural Competency
Individual Counseling Professional Growth
Group Counseling Personal Growth
Family Counseling Dimensions of Recovery
Supervision
Consultation
Community Involvement
Course Work Domain III- Electives-
Community Resources *Electives are additional courses with content within each
Consultation domain which will total 54 hours. By completing electives
Documentation in addition to the required topics, you can satisfy the
HIV Positive Resources requirements for the domains.
- 16 -
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Domain I-Assessment
Required: A total of 54 hours including all of the topics listed below with a minimum of six hours in each category.
Name: ______________________________________________________________________
Course name School or agency sponsor Total clock hours Dates attended
1) ____________________________ ____________________________ ________________ ________________ _______
2) ____________________________ ____________________________ ________________ ________________ _______
3) ____________________________ ____________________________ ________________ ________________ _______
4) ____________________________ ____________________________ ________________ ________________ _______
5) ____________________________ ____________________________ ________________ ________________ _______
6) ____________________________ ____________________________ ________________ ________________ _______
7) ____________________________ ____________________________ ________________ ________________ _______
8) ____________________________ ____________________________ ________________ ________________ _______
9) ____________________________ ____________________________ ________________ ________________ _______
10) ____________________________ ____________________________ ________________ ________________ _______
11) ____________________________ ____________________________ ________________ ________________ _______
12) ____________________________ ____________________________ ________________ ________________ _______
13) ____________________________ ____________________________ ________________ ________________ _______
14) ____________________________ ____________________________ ________________ ________________ _______
Total Hours Submitted _______________
I hereby swear that the information provided above is true to the best of my knowledge.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 17 -
Required
Electives
Initial Interviewing Process
Biopsychosocial Assessment
Differential Diagnosis
Physiology/Pharmacology
of Substance Abuse
Diagnostic Summaries
Committee
Use Only
Committee Use Only
Total number of Core-Training Hours approved by the reviewer: ________________ hours.
Required topic areas missing are: _________________________________________________
Certicate/Verication missing for course titles: ______________________________________
Committee Reviewer: ____________________________________________________________
Compulsive Gambling
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Domain II-Counseling
Required: A total of 54 hours including all of the topics listed below with a minimum of six hours in each category.
Name: ______________________________________________________________________
Course name School or agency sponsor Total clock hours Dates attended
1) ____________________________ ____________________________ ________________ ________________ _______
2) ____________________________ ____________________________ ________________ ________________ _______
3) ____________________________ ____________________________ ________________ ________________ _______
4) ____________________________ ____________________________ ________________ ________________ _______
5) ____________________________ ____________________________ ________________ ________________ _______
6) ____________________________ ____________________________ ________________ ________________ _______
7) ____________________________ ____________________________ ________________ ________________ _______
8) ____________________________ ____________________________ ________________ ________________ _______
9) ____________________________ ____________________________ ________________ ________________ _______
10) ____________________________ ____________________________ ________________ ________________ _______
11) ____________________________ ____________________________ ________________ ________________ _______
12) ____________________________ ____________________________ ________________ ________________ _______
13) ____________________________ ____________________________ ________________ ________________ _______
14) ____________________________ ____________________________ ________________ ________________ _______
Total Hours Submitted _______________
I hereby swear that the information provided above is true to the best of my knowledge.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 18 -
Required
Electives
Introduction to Counseling
Techniques and Approaches
Crisis Intervention
Individual Counseling
Group Counseling
Family Counseling
Committee
Use Only
Committee Use Only
Total number of Core-Training Hours approved by the reviewer: ________________ hours.
Required topic areas missing are: _________________________________________________
Certicate/Verication missing for course titles: ______________________________________
Committee Reviewer: ____________________________________________________________
Domain III-Case Management
Required: A total of 54 hours including all of the topics listed below with a minimum of six hours in each category.
Name: ______________________________________________________________________
Course name School or agency sponsor Total clock hours Dates attended
1) ____________________________ ____________________________ ________________ ________________ _______
2) ____________________________ ____________________________ ________________ ________________ _______
3) ____________________________ ____________________________ ________________ ________________ _______
4) ____________________________ ____________________________ ________________ ________________ _______
5) ____________________________ ____________________________ ________________ ________________ _______
6) ____________________________ ____________________________ ________________ ________________ _______
7) ____________________________ ____________________________ ________________ ________________ _______
8) ____________________________ ____________________________ ________________ ________________ _______
9) ____________________________ ____________________________ ________________ ________________ _______
10) ____________________________ ____________________________ ________________ ________________ _______
11) ____________________________ ____________________________ ________________ ________________ _______
12) ____________________________ ____________________________ ________________ ________________ _______
13) ____________________________ ____________________________ ________________ ________________ _______
14) ____________________________ ____________________________ ________________ ________________ _______
Total Hours Submitted _______________
I hereby swear that the information provided above is true to the best of my knowledge.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 19 -
Required
Electives
Community Resources
Consultation
Documentation
HIV Positive Resources
Committee
Use Only
Committee Use Only
Total number of Core-Training Hours approved by the reviewer: ________________ hours.
Required topic areas missing are: _________________________________________________
Certicate/Verication missing for course titles: ______________________________________
Committee Reviewer: ____________________________________________________________
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signature
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Domain IV-Client Education
Required: A total of 54 hours including all of the topics listed below with a minimum of six hours in each category.
Name: ______________________________________________________________________
Course name School or agency sponsor Total clock hours Dates attended
1) ____________________________ ____________________________ ________________ ________________ _______
2) ____________________________ ____________________________ ________________ ________________ _______
3) ____________________________ ____________________________ ________________ ________________ _______
4) ____________________________ ____________________________ ________________ ________________ _______
5) ____________________________ ____________________________ ________________ ________________ _______
6) ____________________________ ____________________________ ________________ ________________ _______
7) ____________________________ ____________________________ ________________ ________________ _______
8) ____________________________ ____________________________ ________________ ________________ _______
9) ____________________________ ____________________________ ________________ ________________ _______
10) ____________________________ ____________________________ ________________ ________________ _______
11) ____________________________ ____________________________ ________________ ________________ _______
12) ____________________________ ____________________________ ________________ ________________ _______
13) ____________________________ ____________________________ ________________ ________________ _______
14) ____________________________ ____________________________ ________________ ________________ _______
Total Hours Submitted _______________
I hereby swear that the information provided above is true to the best of my knowledge.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 20 -
Required
Electives
Addiction Recovery
Psychological Client Education
BiochemicalMedical Client
Education
Sociocultural Client Education
Addiction Recovery and
Psychological Family Education
Biomedical and Sociocultural
Family Education
Community and Professional
Education
Committee
Use Only
Committee Use Only
Total number of Core-Training Hours approved by the reviewer: ________________ hours.
Required topic areas missing are: _________________________________________________
Certicate/Verication missing for course titles: ______________________________________
Committee Reviewer: ____________________________________________________________
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signature
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signature
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Domain V-Professional Responsibility
Required: A total of 54 hours including all of the topics listed below with a minimum of six hours in each category.
Name: ______________________________________________________________________
Course name School or agency sponsor Total clock hours Dates attended
1) ____________________________ ____________________________ ________________ ________________ _______
2) ____________________________ ____________________________ ________________ ________________ _______
3) ____________________________ ____________________________ ________________ ________________ _______
4) ____________________________ ____________________________ ________________ ________________ _______
5) ____________________________ ____________________________ ________________ ________________ _______
6) ____________________________ ____________________________ ________________ ________________ _______
7) ____________________________ ____________________________ ________________ ________________ _______
8) ____________________________ ____________________________ ________________ ________________ _______
9) ____________________________ ____________________________ ________________ ________________ _______
10) ____________________________ ____________________________ ________________ ________________ _______
11) ____________________________ ____________________________ ________________ ________________ _______
12) ____________________________ ____________________________ ________________ ________________ _______
13) ____________________________ ____________________________ ________________ ________________ _______
14) ____________________________ ____________________________ ________________ ________________ _______
Total Hours Submitted _______________
I hereby swear that the information provided above is true to the best of my knowledge.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 21 -
Required
Electives
Ethical Standards
Legal Aspects
Cultural Competency
Professional Growth
Dimensions of Recovery
Supervision
Community Involvement
Committee
Use Only
Committee Use Only
Total number of Core-Training Hours approved by the reviewer: ________________ hours.
Required topic areas missing are: _________________________________________________
Certicate/Verication missing for course titles: ______________________________________
Committee Reviewer: ____________________________________________________________
Consultation
Personal Growth
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
P.O. Box 45040
Newark, New Jersey 07101
(973) 273-8050
CertifiCAtion And AuthorizAtion form
for A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ (_________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history background process.
Please send no payment now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other Board or Committee of the New Jersey Division of Consumer Affairs, you will not be required
to be ngerprinted a second time. However, the Division must perform a criminal history background check each time you
apply for licensure or certication. The fee for this background check will be $18.75. Payment should be made in the form of
a check or money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
- 22 -
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ _________________________________
Signature of applicant Date
Rev. 1/2/19
- 23 -
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Application For Licensure Or Certification As An Alcohol And Drug Counselor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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