A p p l i c a t i o n s A c c e p t e d

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Amberlynn Gallagher
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1 A p p l i c a t i o n s A c c e p t e d J a n u a r y 1, J u n e 3 0, Test Exemption Application Form January 1, 2016 through June 30, 2016 National Certified Addiction Counselor, Level I (NCAC I) National Certified Addiction Counselor, Level II (NCAC II) I. Personal Data Name: Address: City/State/ZIP+4: Phone: (w) / (h) / (f) / Employer: Payment/Fee Information Amount Enclosed: $.00 Credit card amount: $.00 (All fees are non-refundable) Credential Fee NCAC I $ NCAC II $ (check/money order payable to NCC AP) Company card Personal card MasterCard Visa America Express credit card number / Expiration Date Card holder s signature Card holder s name (please print) Page 1 of 10

Personal Data Name: Address: City/State/ZIP+4: Phone: (w) / (h) / (f) / E-mail: Employer: Payment/Fee Information Amount Enclosed: $.00 Credit card amount: $.

2 II. Certification Eligibility/Application Requirements NATIONAL CERTIFIED ADDICTION COUNSELOR LEVEL ONE Eligibility/Application Requirements Currently hold LAC license. Submission of a signed and dated statement that the candidate has read and subscribes to the NAADAC Code of Ethics. Evidence of 6 contact hours of ethics training and 6 contact hours of HIV/AIDS specific training that occurred during the last 6 years. Completed application with all required supporting documentation. Payment of non-refundable application/certification fee. NATIONAL CERTIFIED ADDICTION COUNSELOR LEVEL TWO Eligibility/Application Requirements Currently hold LAC license. Bachelor s Degree or higher in Behavioral Health. Applicant must submit a copy of official transcript. Evidence of 6 contact hours of ethics training and 6 contact hours of HIV/AIDS specific training that occurred during the last 6 years. Submission of a signed and dated statement that the candidate has read and subscribes to the NAADAC Code of Ethics. Completed application with all required supporting documentation. Payment of non-refundable application/certification fee. Page 2 of 10

Evidence of 6 contact hours of ethics training and 6 contact hours of HIV/AIDS specific training that occurred during the last 6 years.

3 III. Credential Level Please indicate the level for which you are applying: (If you do not meet the eligibility requirements and/or submit an incomplete application, your application will not be accepted. The NCC AP has a no refund policy.) NCAC Level One NCAC Level Two IV. Certification/Education Record Indicate each state credential/license: Credential/License State/Authority Expiration Date Number Note: Copies of current state issued license must be attached. V. Training Hours Attach copies of training/education documentation to include: 6 hours of Ethics 6 hours of HIV/AIDS Note: Training must have occurred within the last six (6) years. Page 3 of 10

Certification/Education Record Indicate each state credential/license: Credential/License State/Authority Expiration Date Number Note: Copies of current state issued

4 VI. Career History In providing your substance use disorders counseling career history, please list your current position first and work backwards until you have documented three years supervised full-time work experience for NCAC I candidates or five years supervised full-time work experience for NCAC II candidates in the addiction profession. Attach additional pages as needed. Employer:_ Address: Job title: Position held from: (month/year) to (month/year) Supervisor: Telephone / Brief job description Page 4 of 10

supervised full-time work experience for NCAC II candidates in the addiction profession. Attach additional pages as needed.

5 VIIa. Professional References PROFESSIONAL REFERENCE # 1 Applicant: Reference s Name/Title: Reference s Address: City, State, Zip: Work phone: Relationship to applicant length of time of acquaintance: Are you licensed/certified as a Substance Use Disorders Counselor? The above applicant is applying for national credentialing as a substance use disorders counselor. It is our request that you provide information to the National Certification Commission for Addiction Professionals regarding the applicant and their relationship with you and others. In addressing interpersonal relationships, it is the belief that these traits impact client care. Your evaluation is of utmost importance in this credentialing process. Strongly Agree Agree Disagree Strongly Disagree Respect for others Care and concern for others Genuineness Empathy Flexibility Judgment Spontaneity Capacity for appropriate confrontation Sense of immediacy Concreteness Page 5 of 10

It is our request that you provide information to the National Certification Commission for Addiction Professionals regarding the applicant and their relationship with you and others.

6 Please complete the following statements: The applicant may be an asset to the field of substance use disorders counseling because he/she is: The applicant may be a liability to the field of substance use disorders counseling because he/she is: General Comments: I do recommend the applicant for certification as a substance use disorders counselor. I do not recommend the applicant for certification as a substance use disorders counselor. I hereby certify that all of the information given herein is true and complete to the best of my knowledge and belief. Signature Date Name (please print) ( ) - Telephone Page 6 of 10

a substance use disorders counselor. I do not recommend the applicant for certification as a substance use disorders counselor.

7 VIIb. Professional References PROFESSIONAL REFERENCE # 2 Applicant: Reference s Name/Title: Reference s Address: City, State, Zip: Work phone: Relationship to applicant length of time of acquaintance: Are you licensed/certified as a Substance Use Disorders Counselor? The above applicant is applying for national credentialing as a substance use disorders counselor. It is our request that you provide information to the National Certification Commission for Addiction Professionals regarding the applicant and their relationship with you and others. In addressing interpersonal relationships, it is the belief that these traits impact client care. Your evaluation is of utmost importance in this credentialing process. Strongly Agree Agree Disagree Strongly Disagree Respect for others Care and concern for others Genuineness Empathy Flexibility Judgment Spontaneity Capacity for appropriate confrontation Sense of immediacy Concreteness Page 7 of 10

8 Please complete the following statements: The applicant may be an asset to the field of substance use disorders counseling because he/she is: The applicant may be a liability to the field of substance use disorders counseling because he/she is: General Comments: I do recommend the applicant for certification as a substance use disorders counselor. I do not recommend the applicant for certification as a substance use disorders counselor. I hereby certify that all of the information given herein is true and complete to the best of my knowledge and belief. Signature Date Name (please print) ( ) - Telephone Page 8 of 10

9 VIII. NAADAC/NCC AP Code of Ethics I understand that as an addiction professional it is my responsibility to safeguard the integrity of the counseling relationship and to ensure that the client is provided with beneficial services. I understand that as an addiction professional I shall provide the client and/or guardian with accurate and complete information regarding the extent of the professional relationship. I understand that as an addiction professional I shall base all recommendations/reports on approved evaluation instruments and procedures as part of the assessment process to promote the well-being of individual clients or groups. I understand that as an addiction professional that confidential information is disclosed when appropriate with valid consent from a client and/or guardian. I shall make every effort to protect the confidentiality of client information, except in very specific cases or situations. I understand that as an addiction professional I shall espouse objectivity and integrity and maintain the highest standards in services provided. I understand as an addiction professional the significance of the role that ethnicity and culture plays in an individual s perceptions and how he/she lives in the world. I shall remain aware that many individuals have disabilities which may not be obvious. I understand that as an addiction professional I shall recognize that the profession is founded on national standards of competency which promote the best interests of society, the client, the individual addiction professional and the profession as a whole. I understand that as an addiction professional in the supervision of others, I shall accept the obligation to facilitate further professional development of these individuals by providing accurate and current information, timely evaluations and constructive consultation. I understand that as an addiction professional I shall attempt to resolve ethical dilemmas with direct and open communication among all parties involved and seek supervision and/or consultation as appropriate. I understand that as an addiction professional, to the best of my ability, I will actively engage in public policy and legislation to make possible opportunities and choice of service for all human beings of any ethnic or social background whose lives are impaired by alcoholism and drug abuse. I hereby attest that I have read, understand, and subscribe to the NAADAC/NCC AP Code of Ethics. Signature Date IX. Candidate Affirmation Page 9 of 10

I understand that as an addiction professional I shall provide the client and/or guardian with accurate and complete information regarding the extent of the professional relationship.

10 I certify that the information on this application is accurate, correct, and complete; and that I have read the NAADAC/NCC AP Code of Ethics and subscribe to it. I also certify that the license presented is not encumbered in any manner and that I do not hold a license/certification from any other state that is or has been subject to criminal or ethical complaint. The National Certification Commission for Addiction Professionals is authorized to contact any institution, organization, or individual listed on or included with this Application for verification of my substance use disorders counseling history. I understand that the National Certification Commission for Addiction Professionals retains ownership of NCAC certificates and may, from time to time, make available certificate holder names and other information to potential service users. Signature Date X. Candidate s Checklist 1. Completed all sections of application. 2. Included check/money order or provided credit card Information (The NCC AP has a no refund policy for any application submitted.) 3. Enclosed evidence of 6 hours of Ethics and 6 hours of HIV/AIDS specific training that occurred in the past 6 years. 4. Enclosed copy of official Bachelor s Degree or higher transcript if applying for NCAC II credential. 5. Enclosed evidence of LAC license. Page 10 of 10

CHECKLIST FOR ADDICTION COUNSELOR RECIPROCITY

CHECKLIST FOR ADDICTION COUNSELOR RECIPROCITY To apply for Reciprocity, you must have met the minimum requirements of certification that would otherwise be required of any applicant through the normal