APPLICATION FOR ADMISSION

Transcription

1 ASSOCIATION OF CHRISTIAN ALCOHOL & DRUG COUNSELORS INSTITUTE ACADC Institute O.C. Headquarters / Spirit of Life Recovery Florida Street, Suite 222, Huntington Beach, CA Office: (714) Fax: (714) PastorBob@SpiritOfLifeRecovery.com Website: SECTION 1. Please print your information clearly. First Name APPLICATION FOR ADMISSION Middle Name Last Name Address (Number, Street, Apt, or Suite No.) City State Zip Telephone Number (including Area Code) Work Number (including Area Code) Address Social Security Number Date of Birth (Month-Day-Year) Male Female ARE YOU REQUIRED TO REGISTER AS A 290 OFFENDER? (Sex Offender) Yes No I declare that the answer that I have provided regarding the question of a 290 sex offender is true. Please sign Date: Page 1 of 5

2 Highest level of education? Check if none apply High school, Diploma High school, GED College, Associate Degree College, Bachelor s Degree Grad school, Master s Degree Grad school, Doctorate Length of time working in a CA licensed or certified AOD treatment facility. Check if none apply Less than 1 year Less than 5 years 5 10 years years HAVE YOU EVER HAD AN AOD CERTIFICATE REVOKED OR SUSPENDED? Yes [ ] No [ ] (If yes please explain on back side of this page) Must submit a clear photocopy of your valid ID, Driver s License, or other government issued ID that shows legal name and photo. SECTION 2. ACADC INSTITUTE CREDENTIAL PROGRAMS (Please check the program(s) or course(s) for which you are registering): CSAC I Entry Level - Christian Substance Abuse Counselor CSAC I (intern level) Application Fee: $ (Includes fee for California Department of Alcohol and Drug program registration for the CCAPP - ACADC Membership 9 Hour Orientation Course, Fee Test Booklet and CSAC I Certificate). Internship must be completed within a state licensed or certified treatment facility. Combination CSAC I, CSAC II, CDAAC Certificate Requires a CSAC 1 plus tuition & fees: $ (CSAC I, II, and CDAAC). This certificate requires 155 hours of classroom or distant learning and clinical experience (160 supervised clinical & 2080 field experience). This meets the requirements for CA State certification through the Department of Health Care Services. Students are responsible for all fees pertaining to taking the state exam when complete. Continuing Education Courses: 40 CEU Packet $100.00, Individual CEU s are $10.00 per CEU Renewal for all ACADC Certificates is $ every 2 years plus 40 CEU s. All certificates held with ACADC will be renewed for this fee. Page 2 of 5

3 RELATED CERTIFICATES Anger Management Instructor - One day workshop - Tuition: $125 for 3 hour course. $395 for the 40 hour course to meet county standards. Domestic Violence Prevention Instructor One day workshop - Tuition: $125 for 3 hour course; $395 for the 40 hour course to meet county standards. Parenting Instructor - One day workshop - Tuition: $125 Crisis Interventionist - One day workshop - Tuition: $125 Addiction Interventionist - One day workshop - Tuition: $125 Codependence Group Instructor - Tuition: $295 Codependence Counselor - Tuition: $395 (must already have a professional counseling credential) Licensed Chaplain- Tuition: $ unless you already have a current CSAC1 then tuition would only be $ (Badges are not included with prices listed, if you would like a Chaplains Badge there is an additional of $200.00). Licensed Clinical Chaplain- Tuition: $ unless you already have a current CSAC1 and a current state approved professional AOD credential issues by an NCCA/ICE accredited organization. Then tuition would only be $ (Badges are not included with prices listed, if you would like a Chaplains Badge there is an additional fee of $200.00). SECTION 3. ACADC INSTITUTE DEGREE PROGRAMS (Please check the program(s) or course(s) for which you are registering): Dual Bachelor Degree and CDAAC Christian Certificate Program - A savings of almost $ over doing these separately - Tuition: $2695 Master level MDAAC Christian Certificate (this upgrade requires a professional or ministry degree and a written paper comparing Faith Based and Secular Counselor Competencies) Certificate Fee: $395 Page 3 of 5

4 ACADC INSTITUTE COLLEGE OF BIBLICAL STUDIES DEGREE PROGRAMS Associate of Ministry in Biblical Addiction Counseling- Tuition: $790 Bachelor of Ministry in Biblical Addiction Counseling - Tuition: $1200 Master of Ministry in Biblical Addiction Counseling - Tuition: $2500 Doctor of Ministry in Biblical Addiction Counseling - Tuition: $3500 Christian Marriage & Family Counselor Certificate (B. Min. with License accredited by the Association of Christian Alcohol & Drug Counselors Institute) Tuition: $2500 Transcript Review - $30 Work Study Program By appointment and availability call (714) (Before we can accept your tuition fee and enroll you in a degree program, you must talk to an ACADC Education Counselor. PastorBob@SpiritOfLifeRecovery.com to make an appointment) SECTION 3. Application submission. The following must be submitted with this application: Non-refundable Registration fee of $395 made payable to ACADC. (This fee covers the cost of your entrance inventory, CSAC I Certificate and the 9 hour Basic Bundle requirement. Upon completion of this, you will be directed to register as an intern with CCAPP (this is required by the Department of Health Care Services before starting an internship). All transcripts from educational institutions that you would like reviewed for credit I understand that the certificates and degree programs for which I am hereby enrolling are granted under the authority of the Association of Christian Alcohol & Drug Counselors and will be subject to the Association's ethical standards described in its code of conduct. I understand that upon completion of all program requirements, the certification or degree for which this application is made will be granted. I acknowledge that all tuition & fees paid go to the work of the Association of Christian Alcohol & Drug Counselors and are non-refundable. I understand that in addition to classroom attendance, it is my responsibility to know and meet all state requirements for certificates I agree to take no legal action against the Association of Christian Alcohol & Drug Counselors or any individual minister, counselor, educator or employee associated with the Association of Christian Alcohol & Drug Counselors. Student s signature: Dated on the day of the month of, 20. I am including a check or money order made payable to ACADC in the amount of: $. Please consult above checklist for your total tuition & fees. Page 4 of 5

5 Return this application with appropriate fees to: ACADC Institute c/o Spirit Of Life Recovery Florida Street, Suite 200 Huntington Beach, CA Please make your check or money order payable to: ACADC Institute Page 5 of 5

6 CALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS REGISTERD ALCOHOL AND DRUG TRAINEE, RADT I APPLICATION/PACKET MS/MR (Circle one) NAME SS# (last four) HOME ADDRESS CITY STATE ZIP HOME PHONE EMPLOYER S NAME WORK ADDRESS CITY STATE ZIP BIRTHDATE(REQUIRED): WORK PHONE JOB TITLE Have you ever been certified, registered or licensed in any profession? Yes No If yes, please indicate where and when you were certified, registered or licensed and the status of such: Applicants (new and renewals) must mail in a completed original RADT I application/packet; failure to do so will result in a delay in the processing of your application/packet. Faxed copies are not accepted, and will be shredded on receipt in the office. The application/packet review takes approximately 2-4 weeks from the receipt of all required items (including fee.) A. Completed original RADT I Application B. Fee of $40.00 (annually) C. A signed and dated Employment letter on letterhead from your Employer verifying employment or, if you are not currently employed, a letter from you stating that you are seeking employment in the field of drug and alcohol counseling (letter must have a current date)/if not employed and you are a student, you must submit proof of enrollment in a SUD course. If neither, you will write your own employment verification of non employment in the field of SUD counseling. D. Signed and dated RADT I Code of Ethics/Conduct (return all pages) E. Signed and dated RADT I Scope of Practice (return all pages) F. Proof of completion of an approved Nine-Hour Orientation Course consisting of ethics, professional boundaries and confidentiality. More information can be found on our website G. Copy of your current Driver s License H. 3 Hours of Law and Ethics completed yearly METHOD OF PAYMENT: 1. Check Money Order (Mail with fee to: CCAPP, Po BOX , Sacramento, CA 95821) 2. Visa MasterCard Amex Discover (Mail to address above) ($30 Fee will be charged for all declined Checks, and $10 fee will be charged for declined credit cards) Card Number Expiration Date 3 or 4 digit Security Code on Back Name as it appears on Card: Signature RADT I Application Page 1 of 6 Billing address for card: No refunds will be authorized whether or not the application is approved or denied.)

7 CALIFORNIA AOD COUNSELORS: CERTIFICANTS AND REGISTRANTS STANDARD UNIFORM CALIFORNIA AOD COUNSELOR CODE OF CONDUCT Adopted: May 2012 Note: This code of conduct does not replace the existing Code of Ethics as defined by the CCAPP CREDENTIALING it merely enhances it. Additionally, the CCAPP CREDENTIALING requires the most stringent rules be applied whether defined by CCAPP CREDENTIALING Code of Ethics or ADP s Uniform Code of Conduct. The current California Regulations governing registrants and certified alcohol and other drug (AOD) counselors require each certifying organization (CO) to develop a code of conduct which establishes minimum standards that are designed to safeguard the rights of clients in AOD programs and facilities. CO s may impose more stringent standards that do not conflict with the standards contained within this Uniform Code of Conduct. Principle 1: Registrants and Certified AOD Counselors shall conduct themselves in an honest, forthright and professional manner. Registrants and Counselors are prohibited from engaging in the commission of any dishonest, corrupt, or fraudulent act substantially related to the qualifications, functions or duties of a registrant or counselor including but not limited to the following: a. Securing a registration, certification or renewal by fraud, deceit or misrepresentation on any application or material in support of any application for registration certification or renewal; b. Misrepresenting the type or status of registration or certification held by the person, or otherwise misrepresenting or permitting misrepresentation of his or her education, professional qualifications or professional affiliations to any person, program or entity; c. Refusal or failure to provide proper identifying registration, credential, certification or license where appropriate or required (e.g., when offering or providing AOD counseling services, on business cards, on informational or marketing materials, etc.); d. Advertising, marketing or promoting programs, services, training, education or experience in a false and misleading manner, as set forth in Business and Professions Code sections 17200, et seq. Code of Regulations (CCR) Title 9, Division 4, Chapter 8, Sections 13000, et seq., as enacted April 1, CCR Title 9, Div. 4, Chap. 8, Section C Principle 2: Registrants and Certified AOD counselors shall maintain professionally appropriate boundaries with clients and family members of clients and shall conduct themselves in a professional, non-exploitive and lawful manner, and are prohibited from: a. Engaging in inappropriate social relationships, sexual relations or soliciting sexual relations with a client or with a former client within two years from the termination date of the counseling relationship; b. Committing an act of sexual abuse, misconduct or an act punishable as a sexually related crime; c. Engaging in a business relationship with clients, patients, program participants, residents and/or other persons significant to them within one year from the termination of the counseling relationship; d. Physically, verbally, sexually harassing, threatening or abusing other staff members, clients, patients, program participants, residents and/or other persons significant to any of the above; e. Unlawfully administering to himself or herself any controlled substance as defined in Section 4021 of the California Business and Professions Code (B&P), or using any of the dangerous drugs or devices specified in Section 4022 of the B&P, or using any alcoholic beverage to the extent, or in a manner, as to be dangerous or injurious to the person holding or applying for a registration, certification or license or to any other person, or to the public. CR Title 9, Div. 4, Chap. 8, Section 13060(f). Principle 3: Registrants and Certified AOD counselors shall comply with all Federal and State Laws and Regulations that pertain to patient/client confidentiality, mandated reporting exceptions, record keeping requirements and patient/client records access. Registrants and Certified AOD counselors are prohibited from: a. Violating client/patient confidentiality except as required or permitted by law including, but not limited to, Title 42 Code of Federal Regulations Part 2, Child Abuse, Elder Abuse and Public Safety laws and Regulations; b. Failing to maintain records consistent with the nature of the services being rendered; c. Refusing or denying patient/client access to charts and records as required by law; RADT I Application Page 2 of 6

8 d. Violating, attempting to violate or conspiring to violate any law or regulation governing AOD registrants, certified or licensed AOD counselor. STATEMENT OF AGREEMENT AND UNDERSTANDING: The undersigned hereby understands and agrees to comply with the CCAPP CREDENTIALING code of ethics and uniform code of conduct as outlined in this document. The undersigned also agrees to abide by the California Department of Alcohol and Drug Program Administrations Code of Conduct outlined in Chapter 8; Subchapter 3, Section The undersigned also understands and consents to the release of information pertaining to registration or certification, any ethical violation(s) and/or sanctions as part of the process of becoming and maintaining a CCAPP CREDENTIALING/CCAPP designation as a member, registrant, or a certificant. The information may be disclosed to the California Alcohol/Drug Program Administration, to the California state-approved certification bodies and/or employers. I further agree not to sue CCAPP or CCAPP CREDENTIALING relative to the certification/examination process and I agree to indemnify and hold CCAPP and CCAPP CREDENTIALING and their respective officers, directors, agents, and employees harmless from any and all liabilities, losses, costs, damages, and any other expenses which CCAPP/CCAPP CREDENTIALING or their officers, directors, agents, and employees may sustain or incur as a result of or arising from the certification examination process. I agree to reimburse CCAPP and/or CCAPP CREDENTIALING for any attorneys fees and costs incurred as a result of my breach of this hold harmless provision. I agree to cooperate with complaint investigations and supply information requested during complaint investigations unless such disclosure of information would violate the confidentiality requirements of Subpart 2, Title 42, Code of Federal Regulations. I understand failure to comply with the Ethics Review Committee or DHCS may result in immediate suspension and/or revocation of my registration or certification until such time I comply. I understand the website will include the term pending until such time the complaint is resolved and/or sanctions are completed by respondent; suspensions and revocations will be posted on the public database (website). Print name: Signature: Date: RADT I Application Page 3 of 6

9 REGISTERED ALCOHOL AND DRUG TRAINEE I SCOPE OF PRACTICE PURPOSE A. To assure a consistent standard of quality education, training and experience for the Registered Alcohol and Drug Trainee, Level I (RADT I) B. Registration is necessary to safeguard the public health, safety, and welfare, and to protect the public from unauthorized service delivery by unqualified alcohol and drug service providers and unprofessional contact by alcohol and drug service requirements. REQUIREMENTS A. Competency requirements shall include the below listed functions taken from TAP 21 as listed below: Screening Intake Orientation Referral Consultation Case Management Crisis Intervention Client, Family & Community Education Report & Record Keeping B. The Registered Recovery Worker, as previously described, must renew registration annually by meeting the following criteria: 1. Will ascribe to the RRW Code of Ethics and the RRW Scope of Practice at each registration renewal period. 2. The Registered Recovery Worker is required to become certified as an Alcohol and Drug Counselor within 5 years of the date of the initial registration as an RRW. ROLE OF THE REGISTERED ALCOHOL AND DRUG TRAINEE I Under general supervision of appropriately qualified staff, the Registered Alcohol and Drug Trainee I shall: A. Assist and support clients with alcohol/drug abuse or dependence, their family members and others to: 1. attain and maintain abstinence as appropriate, 2. develop a program tailored to the individual in support of a recovery process, 3. affect an improved quality of living. RADT I Application Page 4 of 6

10 Under general supervision of appropriately qualified staff, the Registered Alcohol and Drug Trainee I shall; B. Provide quality assistance and support for clients with alcohol/drug abuse or dependence, their family members and others by the following means: 1. providing current and accurate information and education on the disease of alcoholism and other drug dependency issues and recovery processes, 2. assisting in identifying and understanding the defense mechanisms that support addiction, 3. facilitating in self-exploration the consequences of alcoholism and other drug dependence, 4. utilizing the skills and knowledge in screening, intake, orientation, referral, consultation, case management, crisis intervention, client, family & community education, and report & record keeping, 5. assisting in relapse prevention planning and recognizing relapse symptoms and behavior patterns, 6. providing current and accurate information and education to identify and understand the roles of family members and others in the alcoholism/drug dependency system, 7. educating on how self-help groups, such as Alcoholics Anonymous, Al- Anon, Women for Sobriety, Narcotics Anonymous, Secular Organization for Sobriety, Co-dependents Anonymous, etc., complement alcoholism/drug addiction or dependency treatment as well as the unique role of each in the recovery process, 8. assisting clients in establishing life management skills to support a recovery process, 9. facilitating problem solving and the development of alternatives to alcohol/drug use or abuse and related problems of family members and others, 10. utilizing the appropriate skills to assist in developing sobriety life management and communication skills that support recovery, including: Active Listening Intervention Leading Confrontation Summarizing Feedback Reflection Concreteness Empathy Education 11. Maintaining appropriate records in a confidential manner, 12. Providing all services in accordance with the Registering Authority (California Certification Board for Alcohol and Drug Abuse Counselors) signed Code of Ethics and Scope of Practice for Registered Recovery Workers. C. Providing support as part of a treatment team and referring clients, family members and others to other appropriate health professionals as needed. SETTING FOR DELIVERY OF SERVICES A. The Registered Recovery Worker may provide the identified services to individuals with alcohol/drug addiction or dependence, their family members and others in: 1. hospitals, RADT I Application Page 5 of 6

11 DEFINITIONS 2. agencies, 3. other facilities where alcohol and/or drug services are delivered. A. The RRW is a person who must be in the process of becoming certified and has five years from the date of registering with the Certifying Organization (CCAPP CREDENTIALING) received the required education which encompasses a competency-based core of knowledge and skills to assist alcohol/drug-affected persons, as well as those affected by the alcohol/drug affected person. NON-APPLICATION A. Nothing in this Scope of Practice shall be construed to constrict or limit the practice of any other professional licensed by the State of California under the Medical Practice Act, the Social Work Licensing Law, the Nursing Practice Act, the Psychology Licensing Act, or the Marriage, Family and Child Counselors Licensing Law. B. Nor shall the Scope of Practice apply to any priest, rabbi, or minister of the gospel of any religious denomination when performing counseling services as a part of his or her pastoral or professional duties, or to any person who is admitted to practice law in the state, or who is licensed to practice medicine, when providing counseling services as part of his/her professional practice. C. Nor shall this Scope of Practice apply to an employee of a governmental entity or of a school, college, or university or of an institution both non-profit and charitable if his/her practice is performed solely under the supervision of the entity, school or organization by which he/she is employed, and if he/she performs such functions as part of the position for which he/she is employed. Signature: Date: Print Name: RADT I Application Page 6 of 6