Fillable Counselor I (MAADC I) Criteria For Missouri Associate (Missouri Credentialing Board)

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Counselor I (MAADC I) Criteria For Missouri Associate (Missouri Credentialing Board)

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Revised August 2019 MAADC I Application 1
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Criteria For Missouri Associate Alcohol Drug
Counselor I (MAADC I)
I. Criteria for those with an applicable Associate Degree or an applicable
1 year Addiction Certificate program
An applicable Associate Degree or applicable 1 year Addiction Certificate program
3 contact hours of live ethics training (not online or home study)
Signed Mentoring & Clinical Supervision Agreement by a MCB qualified supervisor
Signed Professional Development Contract by a MCB qualified supervisor
II. Criteria for those with a HS Diploma/HSE
HS Diploma/HSE
160 hours of applicable work experience within the last 10 years
3 contact hours of live ethics training (not online or home study)
Signed Mentoring and Clinical Supervision Agreement by a MCB qualified supervisor
Signed Professional Development Contract by a MCB qualified supervisor
APPLICABLE ASSOCIATE DEGREES
(A degree must be from a college or university found in the US Dept. of Education’s database of accredited
schools. The database can be found at http://ope.ed.gov/accreditation.)
1. Psychology 6. Sociology 10. Human Services
2. Social Work 7. Chemical Dependency 11. Art Therapy
3. Criminal Justice 8. Counseling 12. Applied Behavioral Science
4. Family Studies 9. Nursing 13. Education
5. Communication
* If your Related Field Degree (Major) is in one of the above areas but has a different transcript title,
please contact the MCB office at 573-616-2300 to verify it will be accepted as an applicable degree.
APPLICABLE WORK EXPERIENCE
Work experience is defined as supervised work experience in a position with job duties that assist clients in
the recovery process by performing the substance use disorder counselor performance domains. Experience
as a volunteer, intern and/or payment of a stipend qualifies as work experience if the same work is performed
that a paid employee would perform.
All qualifying work experience must have been accrued during the ten (10) years immediately prior to
application being made.
Work experience must be verified by an employment verification form from the agency(s) in which the
applicant has been employed.
Revised August 2019 MAADC I Application 2
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
CHECK LIST FOR MAADC I APPLICATION
1. You have submitted a $110.00 check or money order with this application or have provided your
credit/debit card information on page 5 of this application packet. Applications will not be
reviewed until payment is received.
2. You have completely filled out the application.
3. You have signed the Code of Ethical Practice & Professional Conduct.
4. You have filled out the Family Care Safety Registry Worker Registration Form and included the form
with your packet. If your agency has conducted a FCSR background check on you within the last 30
days, you may submit the results to help expedite the application process.
5. You and your MCB qualified supervisor have signed the Mentoring and Clinical Supervision
Agreement.
6. You and your MCB qualified supervisor have signed the Professional Development Contract.
7. If needed, the appropriate person has completed and signed the Counselor Employment Verification
Form and you have included the completed form with the application.
8. You have submitted proof of 3 contact hours of live ethics training.
9. The appropriate High School/HSE or College transcripts were included with the application.
10. Check the Professional Search on the MCB web site homepage at www.missouricb.com. Type in
your last name. If your application is complete, your credential information will be displayed and
you should have received your welcome letter and certificates by e-mail.
Revised August 2019 MAADC I Application 3
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Application Instructions:
1. Requirements to receive this credential are subject to change without notice. Please make sure you
are submitting the most recent application packet. If you are unsure, contact the MCB office.
2. The application must be typed or neatly printed.
3. Please keep a copy of all materials submitted for your records.
4. FEES: The total MAADC I Fee is $110.00. You may pay either by check, money order, or by
providing credit card information on page 5 of this application packet. Applications will not be
reviewed until payment is received.
5. Please be aware that should your application be reviewed and additional information is requested,
you will have 90 days to provide the requested information. Failure to do so will result in your
application expiring without being approved.
6. All fees are non refundable. If your application is denied or expires, fees will not be refunded.
7. If your application is denied, you may contact the MCB office staff for instructions on how to appeal
the denial of your application.
8. All materials submitted to the MCB office become property of the MCB.
9. The applicant must currently reside and/or be employed in the State of Missouri at least 51% of the
time. The only exception to this is applicants living and working in a state that is not a member of
the International Certification and Reciprocity Consortium.
10. If at any time during the credentialing process, a question arises about an applicant’s moral character,
reputation for honesty, integrity, or professionalism, the Board may either deny the application at that
time or place the application on hold until an investigation has been done and a decision made
regarding the question brought up.
11. MAADC I credential expires one year from the issue date. The MAADC I credential does not renew.
If a professional is not ready to upgrade his/her credential, he/she should reapply for a new MAADC
I credential before the current credential expires.
12. Please remember that it is your responsibility to keep the MCB office informed of any personal
informational changes such as address and phone number changes. If you fail to notify us of changes,
you will be responsible for any material that is mailed to the wrong address and may have to pay a
fee to have the material sent again.
13. Please mail your application to the MCB. Please do not fax or e-mail your application.
Revised August 2019 MAADC I Application 4
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to
those seeking a MCB credential.
1. No individual currently under any type of court supervision can apply for a MCB credential. Please
wait until you are completely free from court supervision before applying.
2. The following items disqualify an individual from ever being credentialed with the MCB:
A. Is listed on the Department of Mental Health disqualification registry
B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept.
of Social Services
C. Any crime against a minor
D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any
of the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only
disqualify an applicant if the crime (s) were a felony. Please view information about Section
630.170, RSMo on the MCB web site www.missouricb.com under the Disqualifying Crimes
Link.
3. If an individual has applied for and been given an exception from the Department of Mental Health,
the individual may apply for a MCB credential. Please send in proof of exception with your
application.
Revised August 2019 MAADC I Application 5
APPLICATION
FOR
Missouri Associate Alcohol Drug Counselor I
(MAADC I)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 2
nd
Floor
JEFFERSON CITY, MISSOURI 65101
TELEPHONE: (573) 616-2300
WEB SITE: www.missouricb.com
EMAIL: help@missouricb.com
Please Mark Credit Card Type:
1. Visa _____________
2. MC _____________
3. Discover _____________
CC Expiration Date: _____/_______
Credit Card #: __________-______________-______________-____________
Credit Card 3 Digit Verification Code: ________________________________
Revised August 2019 MAADC I Application 6
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Please check if you are: ______ New MAADC-I Applicant ______Reapplying MAADC-I Applicant
Applicant’s Name:
________________________________________________________________________
First Middle Last Name Suffix (Jr., II)
_________________________________________________________________________________________________________
Maiden Other Names Used
Current Home Address:____________________________________________________________________________
Street/PO Box Apt. #
____________________________________________________________________________________________________________________
City State Zip County
Home Telephone: ________/_______________ SSN:__________-________-_____________
Work Telephone:
________/_______________, Ext. ________ Cell Number: ________/_________________
E-mail Address:
___________________________________________________________________________
SEX: ____M ____F BIRTH DATE: _____/_____/____________
Are you currently or have you been credentialed or licensed as a Substance Use Disorder Professional by the MCB or
any other state or organization? ______Yes ______No
If yes, which state/organization and when? ____________________________________________________________
What is the type of credential/license held with the other state/organization?
_______________________________________________________________________________________________
Have you ever been ARRESTED and/or CONVICTED of a felony? ____Yes ____No
If yes, please go to the www.missouricb.com website, print off the “Felony Offense Form”, fill out the form and
submit with your application. If you were convicted of a felony listed in Section 630.170 RSMo (view
www.missouricb.com; Disqualifying Crimes link), you may not apply for this credential without an exception from
the Department of Mental Health.
Have you ever knowingly been contacted by a Children’s Division employee regarding a CHILD ABUSE and/or
CHILD NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.missouricb.com website, print off the “Child Abuse/Neglect Statement”, fill out the
form and submit with your application. In addition, please contact the Children’s Division at 573-751-4920 and
request a report of the incident to include with this application.
Revised August 2019 MAADC I Application 7
Education/Degree Information
Please mark your highest level of education completed:
1. High School Diploma/HSE: _____
2. Addiction Certificate Program: _____
3. Associate Degree: _____ Degree Program: ________________________
4. Bachelor Degree: _____ Degree Program: ________________________
5. Master Degree/Higher: _____ Degree Program: ________________________
An applicant may document High School Diploma or HSE or College/University Degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the
applicable degree being conferred.
Where Does the Applicant Currently Work?
Name of Employer:
Mailing Address of Employer Street City State Zip Code County
Name & Title of Immediate Supervisor:
Your Business Phone: Area Code/Telephone Number Extension Fax # Area Code/Telephone Number
TRAININGS/EDUCATIONAL HOURS
All applicants must submit proof of 3 hours of live ethics training.
All training hours must be documented by transcripts, certificates, in-service logs or other means of
qualifying documentation.
Revised August 2019 MAADC I Application 8
Applicant’s Agreement to the Code of Ethical Practice and Professional Conduct
I have read the Current Treatment Code of Ethical Practice and Professional Conduct as
listed on the MCB web site www.missouricb.com
, MCB Ethics Code Link and agree to abide
by this code:
Print Name Date
Signature Date
AUTHORIZATION AND RELEASE
I hereby certify all of the information given herein is true and complete to the best of my knowledge and
belief. I also authorize any relevant investigations, or the release of personal information to the Missouri
Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. I understand
falsification of any portion of this application/renewal will result in my being denied credentialing, or
revocation of same upon discovery.
I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff,
peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any
action that is within the scope and arise out of the performance of their duties which they, or any of them,
may take in connection with this application/renewal, any examination, the grades with respect to any
examination, and/or the failure of the MCB to issue me said credential or renewal.
This Authorization and Release shall also apply to personal information requested by the Board at any
time following credentialing in connection with any investigation concerning allegations that could lead to
disciplinary action against me.
Print Name Date
Signature Date
Revised August 2019 MAADC I Application 9
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
FAMILY CARE SAFETY REGISTRY
WORKER REGISTRATION
PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)
CHILD CARE WORKER ($9.00) PERSONAL CARE WORKER ($9.00) xx VOLUNTARY
REGISTRANT
ELDER CARE WORKER ($9.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00) FOSTER PARENT
(NO FEE)
SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NAME
FIRST NAME
MIDDLE NAME
MAIDEN AND PRIOR NAMES USED
(ATTACH COPY OF SOCIAL
SECURITY CARD)
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
TELEPHONE NO.
(OPTIONAL)
( )
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
CITY
STATE
ZIP CODE
COUNTY
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME
CONTACT PERSON
PHONE NUMBER
( )
ADDRESS
CITY
STATE
ZIP CODE
SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this
form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to
process this request. Futhermore, I authorized the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care
Safety Registry (FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in 210.921, subsection 1
subdivision (1) and (2), RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective
employer/employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child
care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer
of information to the FCSR within thirty (30) days of receiving the results of the background screening determination.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my
signature below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds
from your account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further
collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)
DATE
/ /
IMPORTANT
• Individuals are required to register one time only.
• Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
• Read back of form for instructions and information on registrant notification and appeal rights
• Send completed registration form, copy of Social Security card and required fee to:
Missouri Department of Health and Senior Services
Attn: Fee Receipts
P.O. Box 570
Jefferson City, MO 65102
MO 580-2421 (FP)
Submit this form with your application and a copy of
your SS card. If your agency has ran a FCSR check
within the last 30 days, you can submit the results
with this form which may speed up the application
process. By doing so, you give permission for your
agency to share their FCSR results.
Revised August 2019 MAADC I Application 10
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101; 573-616-2300
MENTORING AND CLINICAL SUPERVISION AGREEMENT
Adapted from Stiehl, R. and Bessey, B. (1994)
THIS FORM MUST BE SIGNED BY A MCB QUALIFIED SUPERVISOR
(MCB Qualified Supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D,
RADC, RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has completed the MCB Clinical
Supervision Training. This cannot be an immediate family member)
Step 1: Agree to work together
• Agree on working together toward improving the supervisee’s counseling skills
Step 2: Define and agree on learning goals
• The learning goals must be clearly defined, and there needs to be agreement to work together to help the
supervisee attain proficiency in the skills chosen
Step 3: Understand the value of the goals
• The supervisee needs to understand the value of achieving the agreed upon goals
Step 4: Break goals into manageable parts
• The overall goals need to be broken down into parts such as: a) the knowledge, b) the skills, c) the
attitudes necessary to attain proficiency
Step 5: Pick styles and methods of learning
• The supervisor needs to elicit from and negotiate with the supervisee his or her preferred styles and
methods of learning
Step 6: Observe and evaluate
• How progress will be observed and evaluated needs to be discussed and agreed upon
Step 7: Provide feedback
• The supervisor needs to know how to give feedback, which guides, corrects, and at the same time
encourages
Step 8: Demonstrate competency and celebrate
• An outcome demonstration of the newly acquired skill which confirms success needs to be designed,
followed by a celebration of the accomplishment
We agree, to the best of our ability to uphold the agreement outlined above and to manage the supervisory
relationship process according to the ethical principles and code of conduct of the MCB.
Applicant Printed Name: ____________________________________ Date: ______________________
Applicant Signature: ________________________________________ Date: ______________________
Supervisor Printed Name: ___________________________________ Date: ______________________
Supervisor Signature: ____________________________________________________________________
Clinical Supervision Training Certificate Number (not credential number): ______________________
Revised August 2019 MAADC I Application 11
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101; 573-616-2300
PROFESSIONAL DEVELOPMENT CONTRACT
THIS FORM MUST BE SIGNED BY A MCB QUALIFIED SUPERVISOR
(MCB Qualified Supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D,
RADC, RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has completed the MCB Clinical
Supervision Training. This cannot be an immediate family member)
Purpose, Goals and Objectives of Supervision:
• Monitor and promote welfare of clients seen by Supervisee
• Promote development of Supervisee’s professional identity and competence by using the tools learned in the Clinical
Supervision: Building Chemical Dependency Counselor Skills Training
• Oversee Supervisee’s entrance and advancement in the credentialing process
• Ensure ethical standards are maintained
Supervision Methods:
• Face to face sessions
• Supervisee attending trainings (both in-service/outside)
• File and documentation review
• Use of forms learned during clinical supervision training (Rubrics, Competency Rating Form, PDP, etc…)
• Preparing the case presentation when applying for certification
Evaluation of Supervisee:
• Feedback will be provided during each face to face session
• A formal evaluation will be conducted every 90 days using the Competency Rating Forms and Professional Development
Plan to identify improvement areas
Supervisee Responsibilities:
• Maintain ethical guidelines and professional standards
• Improve personal knowledge, skills and attitude by following the Professional Development Plan and advice of
supervisor
• Attend trainings to stay current in the field
• Perform all duties while keeping the client’s best interest in mind
We agree, to the best of our ability to uphold the guidelines specified in the supervision contract and to manage the supervisory
relationship process according to the ethical principles and code of conduct of the MCB.
Applicant Printed Name: ____________________________________ Date: ______________
Applicant Signature: ________________________________________ Date: ______________
Supervisor Printed Name: ___________________________________ Date: ______________
Supervisor Signature: __________________________________________________________
Clinical Supervision Training Certificate Number (not credential number): _____________
Revised August 2019 MAADC I Application 12
Note: You do not need to fill this form out for an applicant that is applying at an appropriate Associate
Degree level or higher or a 1 Year Addiction Certificate Program.
COUNSELOR EMPLOYMENT VERIFICATION FORM
An applicant is applying to the MCB for a Missouri Associate Alcohol Drug Counselor I credential. Please
complete this form and provide a copy to the applicant to include with their application.
Applicant’s Name: ___________________________________________________________________________
Supervisor's Name (Print):______________________________________________________________________
Agency: ___________________________________________________________________________________
Address: ___________________________________________________________________________________
___________________________________________________________________________________________
Telephone: _________________________________________________________________________________
E-mail: ____________________________________________________________________________________
Today’s Date: _______________________________________________________________________________
Within the last 10 years from the date listed above, please list the composite total number of hours the
applicant spent working with substance use disorder clients in the following domains: (Please list all hours
worked as this form replaces any previous employment forms submitted with prior applications)
The formula for computing hours is to take the total number of months worked within the last 10 years
and multiply that by 167 hours per month to get the total number of hours. Then divide that total
number as appropriate into the 4 domains below.
Screening, Assessment & Engagement: __________
Counseling: __________
Treatment Planning, Collaboration & Referral: __________
Professional & Ethical Responsibilities: __________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
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Counselor I (MAADC I) Criteria For Missouri Associate (Missouri Credentialing Board)

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