Michigan Development Plan for Clinical Supervisors

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1 Michigan Development Plan for Clinical Supervisors Authority: If the registrant currently does not meet the qualifications to be certified he or she must complete and submit a Development Plan to show they are making reasonable progress toward becoming certified with The Michigan Certification Board for Addiction Professionals (MCBAP). For more information regarding requirements for certification in the State of Michigan, refer to the Credentials Offered or Application Manuals section of the MCBAP website. Objective: The Development Plan contract is an effort to assure the public of the State of Michigan, that the registrant will be provided the conditions and support to make reasonable progress toward becoming certified with the Michigan Certification Board for Addiction Professionals (MCBAP). The Development Plan on file with MCBAP brings about an added layer of protection to the clients served by the agency and public at large. The plan also provides accountability to the Registrant, Clinical Supervisor and the Treatment Agency. The Development Plan will also serve as a method by which statewide data will be collected regarding professional alcohol and drug counselors. The data is important in identifying the ongoing status of the substance abuse workforce in the State of Michigan. The information will assist with identification of future needs, e.g., competency standards, credentialing, training, education, future funding and other planning activities. The aggregate data may be shared with groups such as providers, Regional Substance Abuse Services Coordinating Agencies, elected officials and other interested parties.

2 General Information and Instructions General Information: The Development Plan is required for all individuals not currently certified with MCBAP, providing clinical supervision under public funds. The Development Plan must be completed and submitted to MCBAP within 30 business days of beginning employment. Information must be typed or printed clearly. Agency information should include the official name of all agencies at which you are providing services. The Clinical Supervisor Code of Ethics must be read prior to signing the Development Plan Assurances. The Development Plan cannot be renewed. Time of expiration is decided based on the number of hours you work per week. Typical time given for full-time employment is four years or less. Development Plan must be submitted with a copy of the current job description. Before completing the Development Plan, please read the requirements and instructions for applying for certification. Submit a $50.00 non-refundable processing fee, and forms 1-5. The Development plan can only be completed by an individual holding one of the following reciprocal credentials with MCBAP: CAADC, CADC, CCJP, CCDP, or CCDP-D Demographic Information: This section contains questions for the purpose of providing valuable information that allows current trends in the treatment profession to be identified in the State of Michigan. Only aggregate data may be disseminated to outside entities. Your individual responses will remain confidential. Reporting Status Changes: Notify MCBAP if your name, home address, business address or phone number changes after your Development plan has been submitted. Submit a revised form if your address or employment has changed. If you change agencies this plan is no longer valid until you update it. The revised form needs only to include new information. An additional fee is not required.

3 RECOMMENDATIONS: In order to complete the requirements for certification by the time your Development Plan expires, we recommend you follow the guidelines listed below. These guidelines are based on full-time work (32+ hours per week). Review the requirements, instructions, definitions, and application forms for the certification you will be applying for Experience Hours 2,000 hours per year providing substance abuse counseling at a licensed substance abuse services provider. 1,000 hours per year providing supervision to AOD counselors. Education Hours It is your responsibility to retain proof of completed education hours. 7.5 hours of specific AOD supervision education hours per year in the following areas: 1. Assessment/Evaluation 4. Counselor Development 2. Professional Responsibility 5. Management/Administration 3. Professional Ethics IC&RC Exam Completion 6 months before applying for certification is highly recommended If you fail the exam, you have to wait 60 days before taking it again. A study guide is a useful tool for exam preparation.

4 Application for Michigan Development Plan Clinical Supervisors Form 1 New Plan Update of Information General Information (type or print clearly) Last Name: First Name: MI: Home Address: Telephone: ( ) City: County: State: Zip: Fax: ( ) Social Security #: (last 4 digits) Gender (optional): Female Male Date of Birth / / Primary Race/Ethnic Group (optional): White/Caucasian (non-hispanic) Black/African American (non-hispanic) Native Hawaiian/Pacific Islander Hispanic/Latino Other (please specify) Asian American Native American/Indian Alaska Native Arab/Chaldean Complete the following information regarding your current agency location. Agency Name: Your Title: Street Address: Telephone: ( ) City/Township: Agency address: County: State: Zip: FAX: ( ) Education and Counseling Experience Education Background No High School Diploma High School Diploma or equivalent Some College, no degree Associates Degree Bachelors Degree Masters Degree Doctoral Degree Physician MD/DO Physician Assistant Nurse Practitioner Other (please specify)

5 Certification/Licensure (identify if temporary status) Form 2 APA Addiction specific MAC (NAADAC) LP CEAP NACAII (NAADAC) LLP NBCC NAC-I (NAADAC) LPC LPN NASW ATOD specialty RSST RN LBSW LMSW CHES Other (specify Work Status Salaried Contractual Volunteer How long (years, months etc) have you worked in the substance abuse treatment/prevention field? Typical hours worked per week in substance abuse treatment/prevention How long have you worked as a clinical supervisor? Annual salary from treatment or prevention work $0 - $10,000 $51,000 - $60,000 $11,000 - $20,000 $61,000 - $70,000 $21,000 - $30,000 $71,000 - $80,000 $31,000 - $40,000 $81,000 - $90,000 $41,000 - $50,000 Over $90,000 Type of service in which you spend the majority of your time Prevention Residential Outpatient Recovery Support Medical Care Clinic Other Detoxification Intensive Outpatient Methadone/OTP Supervision/Management/Administration Hospital Acute Care Primary role/responsibility function Primary Therapist Didactics Case Management AAR Screener/Assessor Clinical Supervisor Medical/Psychiatric ACT Team Member Treatment Aide Other Peer Advocate

6 COMPLETION/ASSURANCES: Form 3 Prior to submitting this Development Plan to the Michigan Certification Board for Addiction Professionals (MCBAP) for review, all parties to this agreement: the Applicant and Treatment Agency Director, must fill out and sign and date their respective section of the assurances. Compete the following proposed schedule: Experience Hours Already Completed Year 1 Year 2 Year 3 Year 4 Is future college degree completion part of this plan? Yes No If yes, describe level and expected completion date: Education Hours Already Completed Year 1 Year 2 Year 3 Year 4 Is completion of an academic certificate program part of this plan? Yes No If yes, list the program and completion date: IC&RC Examination Already Completed or Planned Completion Date Overall Target Date of Completion of Plan:

7 Form 4 APPLICANT I. I certify that I prepared all the enclosed Development Plan application materials and this information is true and correct. II. III. IV. I acknowledge I have received, read and understand the Supervisor Code of Ethics and do agree to its terms. I agree to gain the education, supervision and experience necessary to maintain compliance with my Development Plan. I understand that if my Development Plan is suspended or revoked as a result of my breaching the Supervisor Code of Ethics, I will return my certificate to the MCBAP office immediately. V. I understand that my Development Plan cannot be renewed. VI. VII. I understand that if I am pursuing the MCBAP CCS Certification; all requirements needed to obtain certification will be met, and I must be certified by the time of expiration. I hereby authorize MCBAP the release of my name and information in my development plan for review by employers, Regional Substance Abuse Coordinating Agencies and other entities vested in my professional development. Applicant s Start Date of Funded Employment Applicant s Name (type or print clearly) Applicant s Signature Date AGENCY DIRECTOR / ADMINISTRATOR I. I affirm this treatment agency s responsibility and commitment to assist the above named applicant of this Clinical Supervisor Certification Development Plan in gaining the necessary education, training and experience required for certification as a clinical supervisor. This will include but may not be limited to the Certified Clinical Supervisor Performance Domains. II. III. I affirm that the above-identified Clinical Supervisor has been assigned or is contracted to provide the clinical supervision responsibilities for our agency I understand the Development Plan is not renewable and the applicant must be certified by the expiration date of the plan. Agency Name Treatment Agency Director/Administrator s Name (type or print clearly) Treatment Agency Director/Administrator s Signature Date *This will be the start date once the plan is reviewed at MCBAP. The MCBAP office must receive this Development Plan within 30 days of signature.

8 IDENTIFY the PIHP Regional Entity for your primary service area PIHP Regional Entity: Note: Some PIHP s may require a copy of the Development Plan, please check with your PIHP. When completed mail signed Development Plan forms, job description and payment to: Note: Retain a copy for your files MCBAP 6639 Centurion Drive Suite 170 Lansing, MI (517) (517) FAX

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