Fillable PCB CAADC Application 19

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PCB CAADC Application 19

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PCB CAADC Application | Revised October 2019
298 S. Progress Avenue, Harrisburg, PA 17109
Phone: 717-540-4455 Fax: 717-540-4458
www.pacertboard.org info@pacertboard.org
CAADC APPLICATION
Certified Advanced Alcohol and Drug Counselor
The CAADC includes an emphasis on identifying, diagnosing, and/or treating
co-occurring substance use, mental health, and physical health disorders
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
2
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to submitting your application, you must have all requirements completed and documented.
Use the table below as a guide for gathering your documentation.
Do not submit any documentation with your application that is not listed on the table or the
application unless specifically instructed by a staff member. Do not submit your application until
you have completed the application requirements.
REQUIREMENT DOCUMENTATION
✓
Application Page with payment
• Page 7
Experience & Supervision Information
• Page 8
• Previous relevant employment documentation
(if needed).
Current Job Description
• Obtain from employer.
Supervision Documentation Form
• Page 9
Education
• Official transcripts sent directly to Board
•
Copies of trainings (if applicable)
Acknowledgement & Release
• Page 10, notarized
Disciplinary Actions?
• Include letter of explanation with application.
Convicted of a felony?
• Include letter of explanation with application.
Company paying fee?
• Include applicant name on payment.
Copy entire application for records
FOR APPLICANTS WHO HOLD A CURRENT CADC OR CCDP IN GOOD STANDING:
REQUIREMENT DOCUMENTATION
✓
Application Page with payment
• Page 7
Current Job Description
• Obtain from employer.
Education
• Official Master’s degree transcripts sent directly
to Board
Acknowledgement & Release
• Page 10, notarized
Disciplinary Actions?
• Include letter of explanation with application.
Convicted of a felony?
• Include letter of explanation with application.
Company paying fee?
• Include applicant name on payment.
Copy entire application for records
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org
NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not indicate it
has been received. To confirm receipt of your application, email info@pacertboard.org
.
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
3
REVIEW & APPROVAL PROCESS
1. Application submitted to the Board. To confirm receipt of your application, you must email the Board
at the above email address.
2. Staff reviews application. Allow 5- 10 business days for review and processing of your application.
3. Applicant will be emailed if there is any documentation missing from the application or there are
questions regarding your application. It is imperative that you write your email legibly.
4. Your application is considered approved when you receive an email to register for the examination.
5. Follow all instructions to register for the examination provided to you in the email.
6. If you have not heard from the Board regarding your application or received an email to register for
the examination after 10 business days, email info@pacertboard.org
.
7. Once you pass the examination, you are certified.
8. A certificate will be mailed to you automatically within 5-10 business days.
APPLICATION INFORMATION
APPEAL PROCESS
The purpose of appeal is to determine if the Board accurately, adequately and fairly reviewed an application
that is denied. A letter requesting an appeal must be sent to the Board in writing within 30 days of the
notification of the Board's action. An applicant shall be considered notified three days after the relevant date
of mailing. The written appeal will be sent to the Executive Committee who in turn will thoroughly review the
entire application and materials to determine whether or not applicant should have been denied approval. The
applicant will be notified in writing as to the findings of the Executive Committee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the applicant passes the examination. The
certificate issued to the professional lists the following information: name of professional, credential name,
date of issue, date of expiration and certification number.
FELONIES & DISCIPLINARY ACTIONS
While felonies and disciplinary actions from other certification/licensing entities may not prohibit certification,
documentation is required to be submitted at the time of application. Certification through the Board does not
mean a professional should not disclose this information to potential employers and does not in any way
exonerate charges.
INTERNATIONAL CERTIFICATES
A seal will be added to your certificate indicating the international status of your certification. The
International Certificate provides recognition of your status as an internationally certified substance use
disorder professional. Original International Certificates are available for a fee directly from IC&RC at
www.internationalcredentialing.org
. PCB does not issue international certificates.
REQUESTS TO CHANGE APPLICATION
Professionals who wish to have their application re-reviewed for another credential the Board offers prior to
taking the examination, or after an unsuccessful attempt at the examination will incur a $50 application
change/review fee.
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
4
RECERTIFICATION
To maintain the high standards of professional practice and to assure continuing awareness of new knowledge
in the field, the Board requires recertification every two years. Professionals should review the Recertification
Application for credential specific requirements listed on the Board website well in advance of their expiration
date.
EXAMINATION INFORMATION
TYPE OF EXAMINATION
The successful completion of an IC&RC exam is required. The examination is a computer based, 150 multiple-
choice questions and offered on an on-demand basis at an approved testing site. There are several sites in the
state. Candidates may choose the day, time and site.
TIME PERMITTED
Three hours are permitted to complete the examination.
EXAMINATION CONTENT
The examination is developed from the IC&RC Job Analysis which identify domains and tasks for competent
practice.
CANDIDATE GUIDE
The domains, including the task statements per domain, sample exam questions, and a list of references from
the IC&RC Job Analysis are included in the free Candidate Guide. Candidate Guides are available from the
Board website.
STUDY MATERIAL
Professional study guides and practice exams have been published for the examination. Visit IC&RC’s website
for more information: www.internationalcredentialing.org
.
SPECIAL SITUATIONS & ACCOMMODATIONS
Individuals with disabilities and/or religious obligations that require modifications in examination
administration may request specific procedure changes in writing with official documentation to the Board no
fewer than 60 days prior to their examination date. Contact the Board on what constitutes official
documentation. The Board will plan for appropriate modifications to its procedures when documentation
supports this need.
CANCELLATION/RESCHEDULING POLICY
Candidates are required to arrive on time for their examination. Candidates who arrive late will not be
permitted to take the examination and will be charged a $175.00 cancellation/rescheduling fee. Candidates
who cancel or reschedule their examination less than five days prior to their scheduled date will be charged
the full examination fee. Candidates who cancel or reschedule more than five days before their scheduled date
will be charged a $25.00 cancellation/rescheduling fee.
RETESTING
Candidates who fail the examination can retest after a 90 day wait period from the date of their last
examination. Candidates will be sent instructions and fee information. Candidates have three (3) opportunities
to retake an examination. If a candidate fails the examination four (4) times they must submit a study plan and
wait one-year from the date of the final failed examination before they will be permitted to retest again.
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
5
CERTIFIED ADVANCED ALCOHOL & DRUG COUNSELOR REQUIREMENTS
Prior to submitting your application, applicants must have all requirements completed and documented.
DEGREE
The degree must be from an accredited college/university that is recognized by the US Department of
Education or the Council on Higher Education Accreditation. An official transcript sent directly from
college/university is required. If the degree is from outside the United States a degree equivalency must be
done by an organization that specializes in that process. The applicant is responsible for arranging this process
and all costs.
Official transcripts are required and must be sent directly from college/university to the Board office. If your
college/university uses an e-transcript system, they can be emailed directly to the Board. It is recommended
you request transcripts approximately three weeks prior to sending in your application.
• Minimum Master’s degree is required in a relevant field. If your degree is not in a relevant field, the
applicant must apply for the CADC.
EXPERIENCE & SUPERVISION
Qualifying experience is defined as providing primary, direct, clinical, substance use disorder or co-occurring
counseling to persons whose primary diagnosis is that of substance use disorder or providing supervision of
said counseling. Applicant must have primary responsibility for providing substance use disorder counseling in
an individual and/or group setting, preparing treatment plans, documenting client progress and is clinically
supervised. Examples of positions that typically are not approved include: case managers, technicians, peer
and recovery counselors/specialists, intake, admissions, etc.
The applicant must be currently employed in the qualifying position at the time of application. Only
employment within the last seven (7) years may be counted towards the total experience requirement.
If the applicant’s experience requirement is not fulfilled from their current employer, they must include a
letter (on company letterhead) from previous employer(s) verifying their duties and dates employed with their
application.
• Experience: one (1) year of full-time employment or 2000 hours of part-time of employment.
Supervision is a formal or informal process that is evaluative, clinical, and supportive. It can be provided by
more than one person, it ensures quality of clinical care, and extends over time. Supervision includes
observation, mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self-
motivation, learning, and professional development. In all aspects of the supervision process, ethical and
diversity issues must be in the forefront.
• Supervision: 100 hours with a minimum of 10 hours in each domain. Hours may be included in the
total experience requirement.
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
6
CURRENT JOB DESCRIPTION
All applicants must include their current job description with their application. This document is provided by
your employer and must be signed and dated by you and your supervisor. Job descriptions are reviewed as a
part of experience verification. If your supervisor does not have your job description, you should contact your
organization’s Human Resource department. The Board does not provide the job description.
• Current job description: obtained from employer.
EDUCATION
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-
services, college/university credit courses and online education. If you provide this type of education to other
professionals, you may use it towards the education requirement with documentation from the organization
or college/university. Most three-credit college/university courses are 45 hours. There is no time limit on the
use of education for initial certification.
Education review is available prior to application submission with the use of the Education Review Form on the
Board website.
• Education: 180 total hours of education relevant to the field of substance use disorders and co-
occurring disorders.
o Six (6) of the hours must be in professional ethics and responsibilities that are specific to
behavioral health. Ethics courses that are in business, philosophy, religion, etc. are not
accepted.
EXAMINATION
Applicant must pass the IC&RC Examination for Advanced Alcohol and Drug Counselors.
• Domains
1. Screening, Assessment, & Engagement
2. Treatment Planning, Collaboration, & Referral
3. Counseling & Education
4. Professional & Ethical Responsibilities
FEES
The application fee may be paid by check, money order or with VISA, MasterCard, Discover or American
Express. One-half of the application fee is refundable if application is denied or cancelled prior to the
examination. No refund will be issued if application is denied or cancelled after examination. If an employer or
organization is paying the application fee, they must include the applicants name with the payment. Failure to
include the applicants name will result in delay in approval of the application.
• Application Fee: $275/$375 (fee must accompany application and materials)
o Application fee is $275 for applicants with a current CADC or CCDP in good standing.
o
If an applicant has already passed the IC&RC AADC examination, the fee is $175. NOTE: this is
not the same examination that was passed to earn the CADC or CCDP.
• Retest Fee: $175
• Exam Cancellation Fee: $175
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
7
PCB APPLICATION FOR CAADC
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
DOB:
□ Male
□ Female
□ Self-identify _____________________
Name:
SSN: (last four)
Print your name as it should appear on your certificate. Credentials and degrees will not be printed.
Home Address:
City:
State:
Zip:
Email:
Cell Phone:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
Have you ever received any disciplinary action from another certification/licensing authority? □ Yes □ No
If yes, provide full details on a separate sheet.
Have you read and understood the PCB Code of Ethical Conduct? □ Yes □ No
The Code of Ethical Conduct is located at www.pacertboard.org, and click on Ethics.
Military Experience: □ Not Applicable □ Active □ Veteran
Ethnicity: □ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic □ Latino
□
N
ative Hawaiian or Other Pacific Islander □ Not specified: ______________________
Employment plans for the next two years: □ Increase Hours □ Decrease Hours □ No Change □ Seek Advancement
□
R
etire □ Move to a different career □ Unknown
PAYMENT INFORMATION
Do you have a current CADC or CCDP in good standing? □ Yes □ No If yes, the fee is $275; if no, the fee is $375
H
ave you passed the IC&RC AADC examination?
□ Yes □ No If yes, the fee is $175; if no, the fee is $275
APPLICATION FEE CHECK ONE: □ $175 □ $275 □ $375 PCB will charge the correct amount upon approval of application.
FEE CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email for receipt (if paying by credit card only): ________________________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
8
CAADC APPLICATION: EXPERIENCE & SUPERVISION INFORMATION
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Do you need to document previous employment to fulfill the experience requirement? □ Yes □ No
If yes, complete the section below AND submit a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed
must be included with your application.
DO NOT SUBMIT A RESUME WITH YOUR APPLICATION. IT WILL NOT BE REVIEWED AND IT DOES NOT FULFILL THE
DOCUMENTATION REQUIREMENT FOR EXPERIENCE.
CURRENT SUPERVISOR INFORMATION
Immediate Supervisor Name:
Email:
Phone:
Do you have more than one supervisor or need to document supervision from a previous employer? □ Yes □ No
If yes, provide copies of the CAADC Application: Supervision Documentation Form (page 9) to all supervisors. Multiple supervision forms can be
submitted with your application.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE) – LETTER (ON COMPANY LETTERHEAD) FROM
PREVIOUS EMPLOYER(S) VERIFYING YOUR DUTIES & DATES EMPLOYED MUST BE INCLUDED WITH YOUR APPLICATION.
Organization Name:
How many hours did you work per week? ______________________________________________________
Organization Name:
How many hours did you work per week? ______________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Hire Date in Current Position:
Supervisor Position/Title:
Average Number of Hours of Supervision Received Per Week:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
9
CAADC APPLICATION: SUPERVISION DOCUMENTATION FORM
Form to be completed by Applicant’s current and/or previous clinical supervisor(s).
This form is not intended to document all experience or supervision hours of the applicant, rather the minimum hours
required for the certification. Please note: the standard hours accepted for clinical supervision is two (2) hours per week.
If you document more than that for the applicant (your supervisee) you will need to provide documentation to the
Board for the hours to be accepted. This will delay the approval of your supervisee’s application.
Supervision is a formal or informal process that is evaluative, clinical, and supportive. It can be provided by more than
one person, it ensures quality of clinical care, and extends over time. Supervision includes observation, mentoring,
coaching, evaluating, inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional
development. In all aspects of the supervision process, ethical and diversity issues must be in the forefront.
Applicant Name:
CLINICAL SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
CLINICAL SUPERVISION DOCUMENTATION
Clinical Supervision was provided in the following Domains (check all that apply):
DOMAIN:
NUMBER OF HOURS:
□ Screening, Assessment, & Engagement
□
Treatment Planning, Collaboration, & Referral
□ Counseling & Education
□
Professional & Ethical Responsibilities
Supervisor Attestation:
I attest that the above-named applicant is providing primary, direct, clinical, substance use disorder or co-occurring
counseling to persons whose primary diagnosis is that of substance use disorders or providing supervision of said
counseling. They have primary responsibility for providing counseling in an individual and/or group setting, preparing
treatment plans, documenting client progress and is clinically supervised. Current employers: I have provided the
applicant with their job description, reviewed it with them, signed and dated it. Previous employers (if applicable): I
have provided the applicant with a letter (on company letterhead) listing and verifying their duties and dates employed.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF CLINICAL SUPERVISION:
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signature
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PCB CAADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
10
CAADC APPLICATION ACKNOWLEDGEMENTS & RELEASE
This page must be completed by the applicant. It must be notarized and submitted with the application.
RELEASE
I request that the Pennsylvania Certification Board (PCB) grant the credential to me based on the following assurances
and documentation:
• I subscribe to and commit myself to professional conduct in keeping with the PCB Code of Ethical Conduct;
• I certify that the information given herein is true and complete to the best of my knowledge and belief. I also
authorize any necessary investigation and the release of information relative to my credential. Falsification of
any documents will nullify this application and will result in denial or revocation of certification;
• I consent to the release of information contained in my application and any other pertinent data submitted to or
collected by PCB to officers, members, and staff of the aforementioned Board;
• I consent to authorize PCB to gather information from third parties regarding education and employment and
understand that such communication shall be treated as confidential;
• Allegations of ethical misconduct reported to PCB before, during, or after application for certification is made
will be investigated by PCB and could result in the nullification of the application or denial or revocation of
certification.
INITIAL EACH STATEMENT
I have read and understood the Release.
I either live or work in Pennsylvania at least 51% of the time.
I understand one-half of the application fee is refundable if application is denied or cancelled prior to the
examination and no refund will be issued if application is denied or cancelled after examination.
I understand that my application is open for a period of one year after the date of review. If I fail to fulfill all
certification requirements within that year, the application will be closed, and no refund will be issued.
I understand that if I request to have my application re-reviewed for another credential PCB offers prior to
the examination, or after an unsuccessful attempt at the examination I will incur a $50 change/review fee.
Applicant:
Signature:
Date:
PRINT NAME LEGIBLY
NOTARY PUBLIC ONLY
Name:
Date:
I attest that I am a notary public and the above-named applicant satisfactorily proved to be the person whose name is
subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereby set my hand and official seal.
__________________________________________________ SEAL:
Notary Public Signature
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PCB CAADC Application 19

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Completed 28 January 2021

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