Revised Dec 2021 MAADC II Application 1
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 3rd Floor
email: help@missouricb.com Jefferson City, MO 65101
Criteria For Missouri Associate Alcohol Drug
Counselor II (MAADC II)
I. Criteria for those with an applicable Bachelor Degree or higher
Applicable Bachelor Degree or higher
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
II. Criteria for those with an applicable Associates Degree or an applicable 1
year Addiction Certificate program
Applicable Associates Degree or applicable 1 year Addiction Certificate program
1000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Mentoring and Clinical Supervision Agreement by a MCB qualified supervisor
Signed Professional Development Contract by a MCB qualified supervisor
90 Contact Hours of Education to include the following:
3 live ethics hours (not online or home study)
20 of the 90 hours obtained within the prior 12 months of applying
III. Criteria for those with a High School Diploma/HSE
High School Diploma/HSE
2000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Mentoring and Clinical Supervision Agreement by a MCB qualified supervisor
Signed Professional Development Contract by a MCB qualified supervisor
90 Contact Hours of Education to include the following:
3 live ethics hours (not online or home study)
20 of the 90 hours obtained within the prior 12 months of applying
APPLICABLE 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.
Revised Dec 2021 MAADC II Application 2
DEFINITIONS
A. CONTACT HOURS of EDUCATION/TRAINING is defined as workshops, seminars, institutes,
accredited college/university courses, MCB approved home study or on-line courses and in-services. One (1)
contact hour of education is equal to sixty (60) minutes of continuous instruction. 15 contact hours are given
for each college credit. Therefore, a college course of three (3) credits is equal to 45 contact hours.
All education taking place outside the applicant's place of employment must be documented through proof of
attendance including transcripts from an accredited college, letters and/or certificates of completion.
Supporting documentation in the form of brochures, flyers, syllabus, course description, etc. may also be
required to review content for acceptability.
All education taking place within the applicant's place of employment must be documented by title, date and
length of presentation, as well as the name and title of presenter. The training must be verified by the
employee's supervisor who attests the training took place and the employee was a participant in the entire
training.
B. APPLICABLE 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.
C. SUPERVISED PRACTICUM IN THE PERFORMANCE DOMAINS is defined as performance of
the performance domains while under supervision.
Supervision must be provided by someone who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC,
RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has attended the MCB Clinical Supervision
Training.
The supervision of the performance domains may take place within an academic setting and/or within a
supervised work setting. The goal is to receive supervised experience in all of the domains.
D. PERFORMANCE DOMAINS DEFINITIONS: Refer to the ADC Candidate Guide on the MCB web
site at www.missouricb.com under the Education Box/Candidate Guides link.
Revised Dec 2021 MAADC II Application 3
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 3rd Floor
email: help@missouricb.com Jefferson City, MO 65101
CHECK LIST FOR MAADC II APPLICATION
1. You have submitted the $110.00 with this application if you are a new applicant (or $100.00 if
you are an upgrade applicant)
2. You have paid by check or provided your credit/debit card information on page 6 of this
application packet. Applications will not be reviewed until payment is received.
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 and dated the Mentoring and Clinical
Supervision Agreement.
6. You and your MCB qualified supervisor have signed and dated the Professional Development
Contract.
7. You have submitted proof of 3 contact hours of live ethics training.
8. If needed, you have submitted proof of 90 total hours of education/training with 20 of those hours
being obtained within the 12 months prior to application.
9. If needed, the appropriate person has completed and signed the Counselor Employment
Verification Form and you have included the completed form with the application.
10. If needed, a MCB qualified supervisor has filled out the Supervised Practicum Form and you have
included the completed form with the application.
11. The appropriate High School/HSE or College transcripts were sent.
12. 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 Dec 2021 MAADC II Application 4
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 3rd 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 II Fee for new applicants is $110.00. The total MAADC II Fee if upgrading
from MAADC I to MAADC II is $100.00. You may pay by check, money order, or by providing credit
card information on page 6 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. 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.
10. 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.
11. 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 will have to pay a fee to
have the material sent again.
12. Please mail your application to the MCB. Please do not fax or e-mail your application.
Special Instructions For Those Applicants Upgrading
1. Your application is a continuation from your previous application(s). Therefore, you do not need to
submit duplicate information from previous applications such as transcripts. However, you must
complete the application packet in its entirety.
Revised Dec 2021 MAADC II Application 5
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 Dec 2021 MAADC II Application 6
APPLICATION
FOR
Missouri Associate Alcohol Drug Counselor II (MAADC
II)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 3rd 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 Dec 2021 MAADC II Application 7
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Please check if you are: ______ New Applicant ______Upgrade 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 Disorders 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 Childrens 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 Childrens Division at 573-751-1013 and
request a report of the incident to include with this application.
Revised Dec 2021 MAADC II Application 8
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
The number of educational hours needed for the MAADC II depends on what Degree level you have
obtained. Following are the guidelines for educational hour requirements:
1. Applicable Bachelor Degree or higher
3 contact hours of live ethics training (not online or home study)
2. Applicable Associate Degree, 1 year Addiction Certificate program or HS Diploma/HSE
90 total hours
3 contact hours of live ethics training (not online or home study)
20 of the 90 hours obtained within the prior 12 months of applying
All training hours must be documented by transcripts, certificates, in-service logs or other means of
qualifying documentation.
Revised Dec 2021 MAADC II Application 9
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
Be sure to print, sign and date in all places on this page!
click to sign
signature
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Revised Dec 2021 MAADC II Application 10
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
MIDDLE NAME
MAIDEN AND PRIOR NAMES USED
SOCIAL SECURITY NUMBER
(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 Dec 2021 MAADC II Application 11
Missouri Credentialing Board
428 E. Capitol, 3rd 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 Dec 2021 MAADC II Application 12
Missouri Credentialing Board
428 E. Capitol, 3rd 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 Dec 2021 MAADC II Application 13
Note: You do not need to fill this form out for an applicant that is applying at an appropriate Bachelor
Degree level or higher.
COUNSELOR EMPLOYMENT VERIFICATION FORM
An applicant is applying to the MCB for a Missouri Associate Alcohol Drug Counselor II 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: ______________________________________________________________________________________
Revised Dec 2021 MAADC II Application 14
Note: You do not need to fill this form out for an applicant that is applying at an appropriate Bachelor
Degree level or higher.
SUPERVISED PRACTICUM OF THE PERFORMANCE DOMAINS FORM
INSTRUCTIONS: On this form document the number of supervised hours performed in each domain. The applicant must
have completed a total of 300 hours. The applicant must perform a minimum of 10 hours in each domain. The
remaining number of hours needed for credentialing can be in any of the domains.
Supervised hours must be provided by a MCB qualified supervisor only.
(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)
Applicant's Name(Print):___________________________________________________________
MCB Qualified Supervisor (Print):_____________________________________________________________________________
Agency:__________________________________________________________
Clinical Supervision Number:__________________
Total # Supervised Work Hours (Must be a minimum of 300 hours):__________________________________________________
Please indicate on the domain lines below how many of the Total # Supervised Work Hours listed above were in each domain. The
total listed on the line above should equal the sum total of the 4 domains (Must be a minimum of 10 hours listed for each domain):
Screening, Assessment & Engagement: __________ Hours
Counseling: __________ Hours
Treatment Planning, Collaboration & Referral: __________ Hours
Professional & Ethical Responsibility: __________ Hours
MCB Qualified Supervisor’s Signature:____________________________________________
Today’s Date: _____________