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Missouri Credentialing Board CRITERIA FOR REGISTERED ALCOHOL DRUG (Missouri Credentialing Board)

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Revised August 2019 RADC-P 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 REGISTERED ALCOHOL DRUG COUNSELOR –
PROVISIONAL (RADC-P)
I. Criteria for those with an applicable Master Degree
Applicable Master Degree (see list below)
4000 hours of applicable work experience in the performance domains within the last 10
years
2,800 of the 4,000 hours must be in the counseling performance domain
3 contact hours of live ethics (not online or home study)
II. Criteria for those with an applicable Bachelor Degree
Applicable Bachelor Degree (see list below)
6000 hours of applicable work experience in the performance domains within the last 10
years
4,200 of the 6,000 hours must be in the counseling performance domain
3 contact hours of live ethics (not online or home study)
III. Criteria for those with a non-reciprocal credential or license outside of
Missouri
The Board will consider these on a case by case basis however the following 3 items are
required:
•
Proof of 3 contact hours of live ethics (not online or home study)
•
Copy of current credential or license
•
Letter of good standing from current credentialing or licensing board
*Contact the Board office at 573-616-2300 for more information.
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. Human Services 10. Art Therapy
2. Social Work 7. Sociology 11. Nursing
3. Criminal Justice 8. Chemical Dependency 12. Applied Behavioral Science
4. Family Studies 9. Counseling 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 August 2019 RADC-P Application 2
DEFINITIONS
A. 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 hours must be from within the last ten (10) years of applying.
Work experience must be verified by an employment verification form from the agency(s) in which the
applicant has been employed.
CHECK LIST FOR RADC-P APPLICATION
1. You submitted a $160.00 check with this application or provided your credit/debit card information on
page 5 of this application packet. Applications will not be reviewed until payment is received.
2. You completely filled out the application.
3. You signed the Code of Ethical Practice and Professional Conduct.
4. You submitted proof of 3 hours of live ethics training.
5. You 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.
6. You submitted college transcripts.
7. A representative of your agency completed the employment verification form and you have included the
completed form with your application.
8. If applying under criteria number 3 on the first page – you have included a copy of your current
credential or license and have included a letter of good standing from your current credentialing or
licensing board.
Revised August 2019 RADC-P 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 RADC-P Fee for all applicants is $160.00. You may pay 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. 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 deny the application at that time or
place the application on hold until an investigation has been conducted and a decision made regarding the
question.
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 make sure to mail your application to us. Please do not fax or e-mail your application.
13. You may only hold the Registered Alcohol Drug Counselor-Provisional credential
for two years. Those who hold the RADC-P credential are encouraged to pursue
certification or licensure. At the end of two years, the RADC-P will expire and may
not be obtained again by the same applicant. The RADC-P credential is only valid
when working within Missouri substance use disorder treatment programs certified
by the Division of Behavioral Health or operated by the Department of Corrections
or when working as a State employee involved in monitoring, certifying, or otherwise
providing oversight to certified substance use disorder treatment programs.
Revised August 2019 RADC-P 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 RADC-P Application 5
APPLICATION
FOR
Registered Alcohol Drug Counselor-Provisional
(RADC-P)
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 RADC-P Application 6
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
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 RADC-P 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
The number of educational hours needed for the RADC-P:
3 contact hours of live ethics training (not online or home study)
All training hours must be documented by transcripts, certificates, in-service logs or other means of qualifying
documentation.
Revised August 2019 RADC-P 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 RADC-P 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
MAIDEN AND PRIOR NAMES USED
SOCIAL SECURITY NUMBER
(ATTACH COPY OF SOCIAL
SECURITY CARD)
- -
DATE OF BIRTH
/
/
GENDER
MALE
FEMALE
(OPTIONAL)
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
CITY
STATE
ZIP CODE
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
CITY
STATE
ZIP CODE
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME
CONTACT PERSON
ADDRESS
CITY
STATE
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 RADC-P Application 10
COUNSELOR EMPLOYMENT VERIFICATION FORM
An applicant is applying to the MCB for a Registered Alcohol Drug Counselor - Provisional (RADC-P)
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: __________
* With an Applicable Master Degree 4,000 Hours of total applicable work experience in the 4 domains/2,800 of the hours
must be in the Counseling Domain.
* With an Applicable Bachelor Degree 6000 Hours of total applicable work experience in the 4 domains/4,200 of the hours
must be in the counseling domain.
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
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Missouri Credentialing Board CRITERIA FOR REGISTERED ALCOHOL DRUG (Missouri Credentialing Board)

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