Fillable Supervisors Forms Schedule A 300 Hours of Supervised (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Supervisors Forms Schedule A 300 Hours of Supervised (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Supervisors Forms Schedule A 300 Hours of Supervised (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 46 minutes to complete

The Supervisors Forms Schedule A 300 Hours of Supervised (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 6 pages long and contains:

  • 7 signatures
  • 27 check-boxes
  • 142 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

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

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
Schedule A
Supervisor’s Forms
300 Hours of Supervised Practical Training
If you have been previously certied as an alcohol and drug counselor by an
International Certication Reciprocity Consortium afliated board, you may submit verication
from the Addiction Professionals Certication Board of New Jersey in lieu of completing Schedule A.
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
Supervisor(s) name: __________________________________________________________________________________________
You should send a photocopy of this page to every supervisor and/or agency that provided this training.
(All practicum hours must have been completed within the three-year period immediately preceding the submission of this application.)
Core functions of alcohol Hours required When completed (month/year) Supervisor’s signature
and drug counseling
1. Screening 15 hours _________________________ ______________________________
2. Intake 15 hours _________________________ ______________________________
3. Orientation 15 hours _________________________ ______________________________
4. Assessment 15 hours _________________________ ______________________________
5. Treatment Planning 35 hours _________________________ ______________________________
6. Individual Counseling 35 hours _________________________ ______________________________
7. Group Counseling 35 hours _________________________ ______________________________
8. Family Counseling 30 hours _________________________ ______________________________
9. Case Management 20 hours _________________________ ______________________________
10. Crisis Intervention 15 hours _________________________ ______________________________
11. Client Education 15 hours _________________________ ______________________________
12. Referral 15 hours _________________________ ______________________________
13. Consultation 15 hours _________________________ ______________________________
14. Reports/Recordkeeping 25 hours _________________________ ______________________________
I hereby certify that the supervised hours listed above were completed as noted.
__________________________________________________ ______________________________________
Applicant’s signature Date
click to sign
signature
click to edit
Documentation of 3,000 Hours of Related Work Experience
Pursuant to N.J.A.C. 13:34C-2.3(b)
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Instructions: This form should be completed if you are applying for licensure as a clinical alcohol and drug counselor or for certication
as an alcohol and drug counselor. You may make photocopies of this page. Your experience must be in a 12-core-function alcohol and
drug treatment position. Experiential hours may go back only ve years.
All positions being documented must be accompanied by:
• an ofcial job description signed by your supervisor and program director
• a program description (brochure or yer) signed by the program director
• each job must include one Supervisor Evaluation Form (included in this application)
• a current resume of your clinical supervisor
• your current resume (as the applicant).
Applicant’s name: ____________________________________________________________________________________________
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Program director: ____________________________________________________________________________________________
Name of supervisor(s): ________________________________________________________________________________________
Your job title: ______________________________________ Dates of employment: _________________ to _________________
Please put a check in the box next to the title of the position you held. Counselor Intern Trainee Volunteer
(Note: The number of hours indicated in the answers to questions number 2 and 3 must equal the total number of hours indicated
in the answer to question number 1.)
1. How many hours of supervised experience in alcohol and drug counseling are you documenting? ___________________________
2. Of the hours documented in question number 1, how many hours in direct (face-to-face) client counseling are you documenting?
__________________________
3. Of the hours documented in question number 1, how many were spent in all other core-function areas? ______________________
__________________________________________________ ______________________________________
Applicant’s signature Date
__________________________________________________
Employer/ Supervisor’s signature
click to sign
signature
click to edit
click to sign
signature
click to edit
Supervisor Information Form
Please put a check in the box next to the type of application the applicant is submitting.
L.C.A.D.C. application C.A.D.C. application
Note to supervisor: The Alcohol and Drug Counselor Committee of the State Board of Marriage and Family Therapy Examiners believes
that licensure and certication should be based on input from a variety of sources, including the observations of people who supervise the
applicant. For this reason, each applicant is required to obtain an evaluation from a clinical supervisor. Your evaluation, among others, and
data furnished by the applicant will be used in determining eligibility for licensure or certication. As this process can only be effective
with careful and truthful reporting, all information gathered in the evaluation process is condential.
Please return this form and the attached ratings to the address listed on page one. In the event that you cannot rate the applicant on the
items, please indicate so, and return this form to the Committee.
The supervisor must submit a copy of his or her resume or a statement about his or her background with this evaluation.
Applicant’s name: ____________________________________________________________________________________________
Agency’s name: ______________________________________________________________________________________________
Agency’s address: ____________________________________________________________________________________________
Name of supervisor(s): ________________________________________________________________________________________
Title of supervisor(s): ____________________________________ Telephone number (include area code): ____________________
Length of time you have:
A. Known the applicant ________________________________________
B. Provided direct supervision of this applicant _____________________
Please complete:
I hereby certify that I have been in a position to directly supervise the above-named person’s work. In my judgment, this applicant’s
eligibility and professional experience (check one) is is not consistent with licensure or certication standards as set forth by
the Alcohol and Drug Counselor Committee of the State Board of Marriage and Family Therapy Examiners. The information that I am
providing is my best judgment of the above-named person’s capabilities to be: (check one)
licensed as a clinical alcohol and drug counselor, or certied as an alcohol and drug counselor.
The type(s) of supervision I have used with this counselor include those checked below.
Audio/video tapes Case discussions Group supervision One-way mirror observation
Case presentations Individual supervision Telephone consultation Other
__________________________________________________ ______________________________________
Supervisor’s signature Date
Professional licensure, degrees or certications: ____________________________________________________________________
I am a Certied Clinical Supervisor
click to sign
signature
click to edit
Supervisor Evaluation Form
Please put a check in the box next to the type of application the applicant is submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
Evaluator’s name: ____________________________________________________________________________________________
Note: Please rate the applicant in each area using the following scale:
0 = No basis for judgment
1 = Inadequate
2 = Needs development
3 = Acceptable
4 = Good
5 = Outstanding
Area of knowledge, skills or competency
1) Communication
a) Oral __________
b) Written __________
2) Knowledge of Alcoholism/Drug Abuse
a) Physiological __________
b) Pharmacological __________
c) Psychological __________
3) Evaluation and Client Assessment
a) Knowledge of:
i) Human growth and development __________
ii) Family dynamics and interaction __________
iii) Signs and symptoms of alcoholism and drug abuse __________
iv) Signs and symptoms indicating referral for medical,
psychological or other assessment __________
b) Analytical skills:
i) Assessing stages of alcoholism/abuse __________
Area of ethical standards
1) Orientation in all efforts towards a primary goal of recovery for the client and his or her family. _________
2) Respect for condentiality of records, materials and communication concerning clients. _________
3) Respect for the client by maintaining an objective, nonpossessive professional relationship. _________
4) No discrimination among clients or professionals on the basis of race, color, creed, age, sex or sexual orientation. _________
5) Respect for the rights and views of other alcohol and/or drug workers and other professionals. _________
6) Respect for institutional policies and cooperation with management functions.
Initiative toward improving institutional policies and management functions. _________
7) Evidence of genuine interest in helping people with alcohol and/or drug problems and dedication to helping
lead clients to methods of helping themselves as much as possible. _________
8) Willingness to access one’s own personal and vocational strengths and limitations, biases and effectiveness.
The ability and willingness to recognize when it is in the client’s best interest to refer or release him or her to
another individual or program. _________
9) Willingness to take personal responsibility for continued professional growth through further education or training. _________
10) Total commitment to providing the highest quality of care through both personal effort and the utilization of any
other health professional or services which may assist the client in his or her recovery program. _________
Certication
I hereby certify that I have provided a minimum of __________ hours of face-to-face clinical supervision per month including
__________ hours of individual supervision and __________ hours of group supervision.
_______________________________________________ ______________________________________
Supervisor’s signature Date
* Additional comments may be made below.*
click to sign
signature
click to edit
Self-Help Meeting Verication Form
Please put a check in the box next to the type of application you are submitting.
L.C.A.D.C. application C.A.D.C. application
Applicant’s name: ____________________________________________________________________________________________
(Specied below are the minimum number of self-help meetings required for this application.)
Minimum Number of Meetings Required:
A.A. - 5 ALANON - 5 N.A. - 5 OTHER - 15
Date A.A. location Date Name of other self-help groups
(Can include additional A.A., ALANON, N.A. groups
or other self-help groups.)
1) __________________ ___________________________ 1) __________________ ________________________________
2) __________________ ___________________________ 2) __________________ ________________________________
3) __________________ ___________________________ 3) __________________ ________________________________
4) __________________ ___________________________ 4) __________________ ________________________________
5) __________________ ___________________________ 5) __________________ ________________________________
__________________ ___________________________ 6) __________________ ________________________________
__________________ ___________________________ 7) __________________ ________________________________
__________________ ___________________________ 8) __________________ ________________________________
__________________ ___________________________ 9) __________________ ________________________________
__________________ ___________________________ 10) __________________ ________________________________
__________________ ___________________________
__________________ ___________________________ 11) __________________ ________________________________
__________________ ___________________________ 12) __________________ ________________________________
__________________ ___________________________ 13) __________________ ________________________________
__________________ ___________________________ 14) __________________ ________________________________
__________________ ___________________________ 15) __________________ ________________________________
Date ALANON location
1) __________________ ___________________________
2) __________________ ___________________________
3) __________________ ___________________________
4) __________________ ___________________________
5) __________________ ___________________________
Date N.A. location
1) __________________ ___________________________
2) __________________ ___________________________
3) __________________ ___________________________
4) __________________ ___________________________
5) __________________ ___________________________
As required for licensure as a clinical alcohol and drug counselor or certication as an alcohol and drug counselor in the State of New
Jersey, I certify that I have attended the meetings listed on this form.
__________________________________________________ ______________________________________
Applicant’s signature Date
As the applicant’s supervisor, I certify that the applicant has provided documentation that he or she has attended the meetings listed
above.
__________________________________________________ ______________________________________
Supervisor’s signature Date
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Supervisors Forms Schedule A 300 Hours of Supervised (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document