Fillable PCB CS Endorsement Application (Pennsylvania Certification Board)

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PCB CS Endorsement Application (Pennsylvania Certification Board)

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Revised January 2021
INFORMATION & DIRECTIONS
The Certificate of Competency in Clinical Supervision is for professionals who are employed as Clinical Supervisors and is
based on a specific aspect of staff development dealing with the clinical skills and competencies for persons providing
clinical counseling. The format for supervision is commonly one-to-one and/or small groups on a regular basis.
Methods for review often include case review and discussion, utilizing direct and indirect observation of a counselor(s)
clinical work.
The Certificate of Competency in Clinical Supervision is an endorsement available only to those professionals who meet
the experience, education requirement. Credentials must be current, valid, and in good standing.
The endorsement can be obtained at any time once the education and requirements are met. The expiration date of the
endorsement will be the same as the initial, qualifying credential. You must renew the endorsement with your qualifying
credential to maintain it. Your endorsement will be added to your certificate of your qualifying credential.
CHECKLIST
□ Completed application page.
□ Documentation of education.
□ Documentation of experience.
□ Documentation of current job description signed and dated by applicant and supervisor.
□ Application fee.
If there are any issues with the application, you will be notified by email. Applications are open for one year after the
date of review. If an applicant fails to fulfill endorsement requirements within that year, the application will be closed,
and no refund will be issued.
If there are any problems with the application, you will be notified by email. Keep a photocopy of the entire application
for your records.
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
• EMAIL: info@pacertboard.org
NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• FAX: 717-540-4458
Please allow 5-10 business days for review and processing of your application.
To confirm receipt of your application, or check on the status, email info@pacertboard.org.
ENDORSEMENT APPLICATION
Certificate of Competency in Clinical Supervision
PCB | Certificate of Competency in Clinical Supervision Application | Revised January 2021 2
REQUIREMENTS: CERTIFICATE OF COMPETENCY IN CLINICAL SUPERVISION
PREREQUISITE: CAAC, CADC, CAADC, CCDP, CCDPD, or CCJP that is current, valid, and in good standing.
EXPERIENCE: One year full-time or 2,000 hours of part-time employment as a clinical supervisor in the substance use or
co-occurring field.
Qualifying counseling work 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. No
other work experience in the drug and alcohol field can be used for counselor certification other than what is stated
above.
Qualifying clinical supervision work experience is based on a specific aspect of staff development dealing with the
clinical skills and competencies for persons providing counseling. The format for supervision is commonly one-to-one
and/or small groups on a regular basis. Methods for review often include case review and discussion, utilizing direct and
indirect observation of a counselor(s) clinical work.
Qualifying work experience can be from multiple employers to accumulate the required years/hours.
If the applicant’s work experience requirement is not fulfilled from their current employer, they must include
documentation from previous employer(s) verifying their title, duties and dates employed with their application. DO
NOT submit a resume as proof of previous work experience. Applicant must contact previous employers and request
detailed documentation of their employment from them.
The applicant must be currently employed as a clinical supervisor at the time of application.
All work experience must have occurred within the last seven (7) years. Volunteer work is not acceptable. Time spent
participating in or facilitating mutual support groups is not acceptable.
Clinical internships completed as part of a college degree program may be eligible to use toward the required work
experience. Internships must be ones in which the student was providing drug and alcohol counseling as described on
page 10 of this application under Work Experience; internships must be well documented by the agency in which the
internship occurred; internships must have been supervised; internships must appear on the official college transcript.
JOB DESCRIPTION: Current job description signed and dated by supervisor and applicant.
EDUCATION: 30 hours of clinical supervision specific education/training.
• Education is defined as formal, structured instruction: workshops, seminars, in-services, college/university credit
courses and online education.
APPLICATION FEE: $100
RECERTIFICATION
To maintain the Certificate of Competency in Clinical Supervision, recertification is required every two years. The
professional will submit the recertification application with the requirements for their qualifying credential which must
include six hours of approved clinical supervision specific education.
PCB | Certificate of Competency in Clinical Supervision Application | Revised January 2021 3
ENDORSEMENT APPLICATION: CLINICAL SUPERVISION
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
PCB PREREQUITE CREDENTIAL: □ CAAC □ CADC □ CAADC □ CCJP □ CCDP □ CCDPD
Date:
DOB:
□ Male
□ Self-identify ___________________
Name:
SSN: (last four)
Home Address:
City:
State:
Zip:
Cell Phone:
Email:
EMPLOYMENT: Employer: _______________________________ Title: ________________________________
Employer City:
Zip:
Phone:
Hire Date:
Check One:
□ Part-Time
□ Full-Time
Supervisor:
Title:
Supervisor Email:
Have you ever received any disciplinary action from another certification or licensing authority since your
last application or recertification? □ Yes □ No If yes, provide full details on a separate sheet.
PAYMENT INFORMATION: $100 FEE MUST ACCOMPANY APPLICATION
PAYMENT (CHECK ONE): □ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email address for receipt (credit card only): _____________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
PCB | Certificate of Competency in Clinical Supervision Application | Revised January 2021 4
CS ENDORSEMENT: CLINICAL WORK EXPERIENCE & JOB DESCRIPTION
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Total hours/years worked in current position? ___________________________________________________________
I have attached my current clinical supervisor job description, dated and signed by both me and my supervisor.
□ Yes □ No
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.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE)
Letter (on company letterhead) from previous employer(s) verifying your title, duties & dates employed must be included with your application.
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
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PCB CS Endorsement Application (Pennsylvania Certification Board)

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Completed 3 June 2021

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