Included in the application you submit to the Vermont Certification Board should be the following:

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1 1 Dear Certified Alcohol and Drug Addiction Counselor: Thank you for your interest in the Clinical Supervisor (CS) credential. This credential was developed by the International Certification and Reciprocity Consortium (IC&RC) and is recognized internationally. Please note that you must have 5 years (10,000 hours) of substance abuse counseling experience and be an AODA (ADC) counselor or have recertified at least twice before being eligible for this credential. An advanced degree, documented by a sealed, official transcript, may also substitute for some of the work requirement. Included in the application you submit to the Vermont Certification Board should be the following: A copy of your ADC (AODA) certificate The completed biographical data sheet The completed work experience sheet (with hours totaled) The certification of work experience sheet signed by your supervisor Your training hours listed and documented The signed code of ethics sheet Documentation of 6 hours of ethics training specific to supervision responsibilities A sealed, official transcript, if applicable (may be sent directly from institution) Please note that the fee for this credential is $ which should be paid via PayPal in two installments: $75.00 for the application review and $ for the written exam once the application has been approved by the board. PLEASE NOTE THAT ALL FEES ARE NONREFUNDABLE. Therefore, it is extremely important that you meet all of the criteria before submitting an application. These criteria may be found on our website. The CS written exam is a computer based, ondemand examination. Consult our test schedule, also on our website. In addition, the board asks that you refrain from submitting any extraneous material as this greatly slows the application review process. Please feel free to call Nan Kolok at the Vermont Certification Board office at if you have questions or need further clarification.

2 Clinical Supervisor (CS) Name (last, first, middle initial) BIOGRAPHICAL DATA Home Address (street & no., city, state, zip) Phone Home: Work: Date of Birth (month, day, year) Cell: Male address Female Home: Work: Schools Attended Location Dates Attended Grade or Degree 1. I live or work 51% of the time within the Certification Board s jurisdiction. Yes No 2. List any other states in which you are certified: 3. Have you been convicted of a crime other than a minor traffic violation? Yes No 4. Has certification been denied or revoked in another state? Yes No If yes to numbers 3 or 4 above, you must explain on a separate sheet. I hereby certify that all information I have provided in this application is true and accurate to the best of my knowledge. Should I furnish any false information on this application, I hereby understand that such an act shall constitute cause for denial of my application for licensure / certification as an alcohol and drug abuse counselor. Signature Date The Alcohol and Drug Abuse counselor Licensing Rules meant to implement the provisions of Title 33, chapter of the Vermont Statutes Annotated (VSA), #5, Et Standards, state that "Vermont alcohol and drug abuse counselors must comply with the conduct standards listed at 3 VSA 129a and 33 VSA 810. Attachment B Rule is designed to further describe specific principles of moral fitness and behavioral standards under 33 VSA 810 (3)." Rev. Nov Page 2

3 ALCOHOL / DRUG RELEVANT PAID WORK EXPERIENCE (most recent first) Employer: Dates: From To Total Hrs Address: Phone No. Your Title: Treatment Services Supervisor: Percent of time providing alcohol/drug services as per 12 core functions: % Duties as they relate to 12 core functions: Clinical Supervisor s name: (if different from above) Address: Hours worked in 12 core functions (Multiply total hrs. X % listed) Telephone No.: Employer: Dates: From To Total Hrs Address: Phone No. Your Title: Treatment Services Supervisor: Percent of time providing alcohol/drug services as per 12 core functions: % Duties as they relate to 12 core functions: Clinical Supervisor s name: (if different from above) Address: Hours worked in 12 core functions (Multiply total hrs. X % listed) Telephone No.: Rev. Nov Page 3

4 CLINICAL SUPERVISION EDUCATION AND TRAINING Name: Please list the trainings you have attended and the number of hours earned from each for this credential. Attach documentation in order. In addition, please indicate which area(s) each training addressed in particular, using the following codes: 1=Assessment/Evaluation, 2=Counselor Development, 3=Management/Administration, 4=Professional Responsibilities. Dates From: To: Training Events List most recent first, etc. Title of Course Training Organization Hours of Training Code(s) Rev. Nov Page 4

5 CODE OF ETHICS FOR VERMONT SUBSTANCE ABUSE CLINICAL SUPERVISORS 1. Code of Ethics: This code of ethics applies to Alcohol, Tobacco and Other Drugs (ATOD) Substance Abuse Professionals who are credentialed as Clinical Supervisors (ATOD/CS) and applies to their conduct during the performance of their clinical duties as supervisors. 2. Supervision: Supervision is a disciplined, structured and defined clinical activity. It has a parallel, but linked relationship to education, consultation, administration and research. It is a necessary, significant and meaningful aspect of the delivery of ethical, competent, humane, and appropriate services to clients/consumers. 3. Rules of Conduct: These ethics constitute the standards an ATOD/CS should maintain. These ethics shall be used to aid in resolving any ambiguity, which may arise in the application and interpretation of these rules. 4. Competence: An ATOD/CS shall limit practice to areas of competence in which proficiency has been gained through education or documented experience or through the awarding of a reciprocal professional certification or license. An ATOD/CS shall accurately represent areas of competence, education, training, experience and professional affiliations in response to responsible inquiries, including those from appropriate boards, the public, supervisees, and colleagues. An ATOD/CS shall aggressively seek out consultation with other professionals when called upon to supervise counseling situations outside their realm of competence. An ATOD/CS will refer supervisees to other professionals when they are unable to provide adequate supervisory guidance to the supervisee. 5. Client Welfare and Rights: The primary obligation of an ATOD/CS is to train S/A counselors to respect the integrity and promote the welfare of their clients. ATOD/CS should have supervisees inform and receive permission from clients that they are supervised and that details of their treatment may be discussed or reviewed with a supervisor. Any audio or video taping of a client/consumer's treatment must be authorized in writing. An ATOD/CS should make supervisees aware of client's rights, including protecting client's rights to privacy and confidentiality in the counseling relationship and the information resulting from it. Clients should also be informed that their right to privacy and confidentiality will not be violated by the supervisory relationship. Records of the supervisory relationship, including interview notes, test data, correspondence, the electronic storage of these documents, audio and video recordings are to be treated as confidential materials. Written permission for use of these materials outside of the supervisory session must be granted in writing by the client. An ATOD/CS is responsible for monitoring the professional actions of their supervisees. An ATOD/CS is responsible for monitoring the professional actions of their supervisees. An ATOD/CS is responsible for the presentation of adequate training for all supervisees in the area of transference, dual relationships, cultural sensitivity and professional deportment. Rev. Sept Page 5

6 6. Professional Behavior: Due to the unique scope of practice S/A counselors provide, ATOD/CS must monitor the following behaviors of their staff and themselves: 7. Supervisory Role: a) Conviction for the possession or use of any illegal drug, narcotic or mood altering substance. b) The use of intoxicants and/or non-physician prescribed and monitored moodaltering substance when engaged in professional pursuits. c) The conducting of intimate, personal, and/or business relationships of any kind with any client or their families. This applies to all clients. A supervisee should have all relationships of this kind reviewed. An ATOD/CS should consult with an objective peer when the issue is raised. d) ATOD/CS Counselors who are members of Alcoholics Anonymous, Cocaine Anonymous, Narcotic Anonymous, Al-Anon, etc. shall not become a sponsor to any active, discharged client or family member. e) ATOD/CS Counselors are in violation of this code and are subject to revocation and/or other appropriate action if they: 1. Are convicted of any felony 2. Are convicted of a misdemeanor related to their qualifications or functions 3. Engaged in conduct that could lead to a conviction of a felony or misdemeanor related to their qualifications and/or function 4. Are expelled or disciplined from any other professional organization 5. Have their license or certification revoked, suspended or disciplined by a regulatory body 6. Shall refuse to seek treatment if deemed impaired 7. Fail to cooperate in any ethical complaint investigation f) ATOD/CS respects the dignity and protects the welfare of participants in research and are aware of regulations and professional standards governing research including informed consent. g) ATOD/CS makes financial arrangements with clients, third party payers and supervisees that are understandable and conform to accepted professional practices. Supervisors do not allow the agency and/or supervisees to accept payment for referrals. Clinical Supervisors disclose any fees to the clients and supervisees at the beginning of services and represent facts truthfully to clients, third party payers and supervisees. h) ATOD/CS Counselors accurately represent their level of competence, education, training and experience relevant to their role of supervision and clinical experience. The Clinical Supervisor assures that any advertisement and/or promotional material accurately conveys information that is necessary for the public to make an informed choice for selection of services. Inherent and integral to the role of supervisor are responsibilities for monitoring of client welfare, insuring compliance with relevant legal and professional standards of service delivery, monitoring clinical performance and professional development of supervisees and evaluating and certifying current performance and potential of supervisees for academic, screening, selection, placement, employment, and credentialing purposes. Rev. Sept Page 6

7 a) The Clinical Supervisor must maintain professional decorum and standards. Unprofessional behaviors outlined in #6 above will not be tolerated. b) An ATOD/CS should pursue professional and personal continuing education activities to maintain their AOD/CS credential and to improve their supervisory skills. Competency in the Four Performance Domains of ATOD Clinical Supervision must be maintained. c) An ATOD/CS shall make their supervisees aware of professional and ethical standards and legal responsibilities of the counseling profession. In the absence of agency or state policy industry standards of ethical behavior should be explained to the supervisee. d) An ATOD/CS should strive to enable supervisees to be competent, autonomous, professional, judicious, aware of limitations and to become future supervisors if that is an appropriate career goal. e) Procedures for contacting the supervisor, or an alternative supervisor, to assist in handling crisis situations should be established and communicated to supervisees. f) Actual work samples via audio, counselor report, video or observation should be part of the regularly scheduled supervision process. g) Supervision is maintained through regular face-to-face meetings with the supervisee in group or individual sessions. h) An ATOD/CS should provide supervisees with ongoing feedback on their performance. i) An ATOD/CS who has multiple roles (e.g., teacher, clinical supervisor, administrator, etc.) with supervisees should avoid any conflict of interest caused by these disparate roles. The supervisee should know the limitations placed on the AOD/CCS and the supervisor should share supervision when appropriate. j) An ATOD/CS should not participate in any form of sexual contact (including sexual harassment and sexual advances) with supervisees. Supervisors should not engage in any form of social contact or interaction, which would compromise the supervisor-supervisee relationship. Dual relationships (including outside consultants, partnerships, nepotism, etc.) with supervisees that might impair the supervisor's objectivity and professional judgment should be avoided and/or the supervisory relationship terminated. k) ATOD/CS shall not use the supervision process to further personal, religious, political or business interests. I) ATOD/CS should not endorse any treatment that would harm a client either physically or psychologically m) An ATOD/CS should not establish a psychotherapeutic relationship as a substitute for or as an addition to supervision. Personal issues should be addressed in supervision only in terms of the impact of these issues on clients and on professional functioning. n) An ATOD/CS should never supervise past or current clients who are staff or their families. 0) An ATOD/CS should model appropriate use of supervision themselves for problem solving and practice review. p) An ATOD/CS must be straightforward with supervisees about observed professional and clinical limitations of the supervisee. These concerns must be clearly documented and shared with the supervisee. q) An ATOD/CS, who is a member of Alcoholics Anonymous, Narcotics Anonymous, Al Anon, etc., should never sponsor a supervisee. r) An ATOD/CS should not endorse a supervisee for certification or credentialing if the supervisor has documented proof of impairment or professional limitations that Rev. Sept Page 7

8 would interfere with the performance of counseling duties in a competent and ethical manner. The presence of any such impairment should begin with a process of feedback and remediation whenever possible so that the supervisee understands the nature of the impairment and has the opportunity to remedy the problem and continue with his/her professional development. s) An ATOD/CS should incorporate the principles of informed consent and participation; clarity of requirements, expectations; roles and rules; and due process and appeal into the establishment of policies related to progressive discipline. t) An ATOD/CS must be able to integrate the 12 Core Functions of Substance Abuse Clinical Competency into their theoretical and supervisory approach. A clear understanding of the 46 Global Criteria is essential. u) An ATOD/CS ensures the professional quality of the program that their supervisees participate in. v) An ATOD/CS should be an active participant in quality assurance and peer review. w) The supervision provided by an ATOD/CS must be provided in a professional and consistent manner to all supervisees regardless of age, race, national origin, religion, physical disability, sexual orientation, political affiliation, marital, social or economic status. When a supervisor is unable to provide non-judgmental supervision a referral to an appropriate supervisor with a complete explanation to the supervisee must be made. Applicant Signature: Date: Rev. Sept Page 8

9 CERTIFICATION OF WORK EXPERIENCE I certify that has at least 2 years (4,000 hours) (name of candidate) of clinical supervisory experience in the AODA field and that this experience includes a minimum of 200 contact hours of face-to-face clinical supervision. (printed name of supervisor) (date) (supervisor s signature) Rev. Sept Page 9

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