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New Jersey Ofce of the Attorney General PROPOSED (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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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
PROPOSED PLAN OF C.A.D.C. SUPERVISION
(To be submitted by supervisor.)
(N.J.A.C. 13:34C-6.3(m))
Date:_________________________
C.A.D.C.name:______________________________________________________________________________________________
C.A.D.C.address:____________________________________________________________________________________________
StreetorP.O.Box CityState ZIPcode
Certicationnumber:__________________________________________Datecertied:___________________________________
Supervisor’s Information (Please print clearly.)
(If the C.A.D.C. is supervised by more than one supervisor, submit a separate form for each supervisor.)
Supervisor’sname:____________________________________________________________________________________________
LastnameFirstname Middleinitial
Licensenumber:_________________________________________________Datelicensed:________________________________

(Listalllicensenumbers)
College/University:____________________________________________Graduateddegreetitle:____________________________
Dateawarded:___________________________LicenseorApplicationNumber:__________________________________________
Supervision credential (N.J.A.C. 13:34C-6.3(a)):
Licensure of proposed supervisor: (Check all that apply.)
L.C.A.D.C. L.P.C. L.M.F.T.
CertiedAPN L.C.S.W.  LicensedPsychologist
CCSCredential 

Yes No
Physician, A.S.A.M./A.B.A.M.Certied? 

Yes No
Psychiatrist, A.S.A.M./A.B.A.M.Certied? 

Yes No
HastheProposedSupervisoreverhadalicenserestrictionimposedwhichprohibitedthesupervisionofothers?

Yes No
HastheProposedSupervisoreverbeendisciplinedbyanyprofessionallicensingboard?

Yes No
Practice/Agency Name and Location
(If more than one location, submit a separate form for each location.)
Name:______________________________________________________________________________________________________
Agency/Business
Address:____________________________________________________________________________________________________
StreetorP.O.Box CityState ZIPcode
Telephonenumber:________________________________E-mailcontact:______________________________________________

(includeareacode)
Webpage:_________________________________________Datesupervisioncommenced:________________________________
C.A.D.C.jobtitle:____________________________________________________________________________________________
Numberofhoursofindividualsupervisionperweek____________Numberofhoursofgroupsupervisonperweek_____________
For Ofcial Use Only
Approved:

Yes
No
Date:___________________
IcertifythatIhavereadandwillcomplywiththestatute,N.J.S.A.45:2D-1etseq.,andtheregulationsatN.J.A.C.13:34Crelatedto
thescopeofpractice,generalobligations,clientrecords,condentialityandclinicalsupervisioninthissupervisoryrelationshipandhave
reviewedtheregulationswiththeC.A.D.C.
IunderstandthatIamultimatelyresponsibleforthetreatmentandwelfareoftheclient.
Asthesupervisor,areyouawareofanyrestrictiononthesupervisee’scertication?    

Yes No
If“Yes,”pleasedetailrestriction._________________________________________________________________________________
DoyouhaveanyotherrelationshipwiththeC.A.D.C.(seeN.J.A.C.13:34C-6.3(i))?

Yes No
If“Yes,”pleasesubmitawrittenstatementwithdetailsofthatrelationship.
THE SUPERVISOR IS REQUIRED TO IMMEDIATELY NOTIFY THE ALCOHOL AND DRUG COUNSELOR
COMMITTEE OF ANY CHANGES IN THE EMPLOYMENT OF EITHER THE C.A.D.C. OR THE SUPERVISOR.
Certication
Icertifythatalloftheforegoinginformationprovidedhereinistrueandifanyinformationprovidedbymeiswillfullyfalse,Iamsubject
todisciplinaryaction.
Supervisor’ssignature:__________________________________________________________________________________________
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New Jersey Ofce of the Attorney General PROPOSED (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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