New Jersey Ofce 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 SUPERVISION FOR C.A.D.C./L.C.A.D.C. INTERNSHIP
Has the INTERN read the regulations re: Alcohol and Drug Counselor Internships? Yes No
Has the SUPERVISOR read the regulations re: the clinical supervision of Alcohol and Drug Counselor Interns?
Yes No
Date: _________________________
Intern Information
Name: ______________________________________________________________________________________________________
Last name First name Middle initial
Mailing address:______________________________________________________________________________________________
Street or P.O. Box City State ZIP code
Home telephone number: ________________________________ Cellular telephone number: _______________________________
(include area code) (include area code)
Date of birth: __________________
Month Day Year
1. How many of the 270 core-training hours in Addiction Studies has the INTERN already completed? ___________ of the 270.
(See Schedule B of the C.A.D.C./L.C.A.D.C. application.)
2. Does the INTERN hold a degree from a college or university?
Yes No
(Include this information in the attached resume.)
3.
Does the INTERN hold another clinical license at this time, making him/her a CREDENTIALED INTERN?
Yes No
(Include this information in the attached resume.)
Proposed Internship/Worksite Setting: (check one)
Division of Addiction Services Licensed Agency Other Agency
Private/Group Practice
Other
Name of Work/Internship Setting: ________________________________________________________________________________
Address of Worksite:___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
Telephone number: ________________________________
Tax status: For-prot Not-for-prot
(include area code)
Attach the following to this application and return it to:
Alcohol and Drug Counselor Committee
P.O. Box 45040
Newark, New Jersey 07101
1. The resume of the INTERN (include formal academic information if available).
2. The resume of the SUPERVISOR (include academic, licensure and certication information).
3. A brochure (or description) of the agency/program or practice setting.
4. A copy of the written Internship Agreement between the Intern and the Supervisor.
5. A copy of the Agency’s Client Disclosure form, pursuant to: N.J.A.C. 13:34C-6.2(c).
For Ofcial Use Only
Approved:
Yes
No
Date: ___________________
