New Jersey Office of the Attorney General
Division of Consumer Aairs
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
CADCTempLicense@dca.njoag.gov
Proposed Plan of Supervision Addendum
(To be submitted by Supervisor)
This document is to be completed by CADC intern’s supervisor and submitted to
Committee and not by the applicant. This will be matched with an approved plan of supervision on le.
If there is no approved plan on le, then both the proposed plan and this addendum need to be submitted.
I, _________________________________________________________, licensed as _____________________________
_______________, license number ______________________________, through personal knowledge or having reviewed
documentation supplied by ______________________________ (intern), date of birth _____________________________,
and veried that information, certify:
1. Intern has completed at least 150 hours of the 270 hours of core content education required of a CADC pursuant to
N.J.A.C. 13:34C-2.3(b)(4).
2. Intern has completed at least 300 hours of the 3000 hours of supervised work experience in drug and alcohol
counseling required of a CADC pursuant to N.J.A.C.13:34C-2.3(b)(3).
3. Intern has conrmed to me that intern has attended at least fteen of thirty alcohol and drug abuse self-help group
meetings required of a CADC pursuant to N.J.A.C. 13:34C-2.3(b)(5).
4. I am aware that the temporary CADC credential will permit the intern to provide drug and alcohol counseling services
via telemedicine and telehealth at my direction and under my supervision, consistent with N.J.S.A. 45:1-61 et seq.
and P.L. 2020, c.3.
5. I am aware that any temporary certication issued under Administrative Order 2020-13 will remain in eect for the
duration of the public health emergency or state of emergency declared in Executive Order 103, whichever is
later, unless expressly revoked or superseded by a subsequent Administrative Order.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me
are willfully false, I am subject to punishment.
__________________________________________ ______________________________________________
Date Signature of Supervisor
Once completed please send this addendum to:
CADCTempLicense@dca.njoag.gov
AO-2020-13
Waiver 2020-12
click to sign
signature
click to edit
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