CERTIFIED CLINICAL SUPERVISOR CS Application. January 1st April 1st July 1st October 1st

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1 New Mexico Credentialing Board for Behavioral Health Professionals P.O. Box Albuquerque, NM CERTIFIED CLINICAL SUPERVISOR CS Application Mail completed packet to NMCBBHP P.O. Box Albuquerque, NM APPLICATION DEADLINES (Must be postmarked on or received before) January 1st April 1st July 1st October 1st Exams are held in March June September December For more information contact the board at:

2 CLINICAL SUPERVISOR CREDENTIAL (CCS) The ICRC defines Clinical Supervision as a specific aspect of staff development dealing with clinical skills and competencies for persons providing counseling. The format for supervision is commonly one to one and/or small groups on a regular basis. Methods for review often include case review and discussion, utilizing direct observation of counselor s clinical work. A primary purpose of clinical supervision is to ensure skill development evidence in quality patient/client care. The NMCBBHP has adopted the following ICRC standards for a Clinical Supervisor Credential (CCS) and for the purpose of granting reciprocity. Prerequisite: Certification as a CADAC/AODA counselor at the reciprocal level. Experience: Five (5) years (10,000 hours) of counseling experience as a CADAC counselor. Degree substitutions as outlined in the IC&RC AODA counselor standards shall apply. The experience requirement is verification of two (2) years (4000 hours) of clinical supervisory experience in the AODA field. These two (2) years may be included in the five (5) years of counseling experience and must include the provision of 200 contact hours of face-to-face clinical supervision. Education: Thirty (30) hours of didactic training in clinical supervision. This must include a minimum of six (6) of education in each of the performance domains of the current IC&RC/AODA role delineation study. Education must be specifically related to the knowledge and skills necessary to perform the tasks with IC7RC/AODA following performance domains: Assessment/Evaluation, Counselor Development, Management and/or Administration, and Professional Responsibilities Supervisory Experience: Two (2) years or (4,000) hours) of clinical supervisory experience in the AODA field. These two (2) years may be included in the five (5) years of counseling experience and must include the provision of two hundred (200) contact hours of face-to-face clinical supervision. Code of Ethics: The applicant must sign a code of ethics a statement of affirmation that the applicant has read and will abide by the Certification Board Ethical Standards of Alcohol and Drug Abuse Counselor. The applicant must agree to the jurisdiction of the Certification Board by signing the Statement of Understanding/Authorization and Release. Reference: Submission of three (3) references from individuals familiar with the applicant s work as a clinical supervisor, one of who must have supervised the candidate s clinical supervision. EXAMINATION: Passing of the IC&RC examination of Clinical Supervisors. Fees: $200 = ($50 for the application review; $150 for the IC&RC Exam). The fee must accompany the application packet. Note: Only training hours documented/received within the past five (5) years, prior to the date of submitting your application packet, will be accepted. Recertification: 40 (forty) contact hours (CEU s) must be completed within the 2-year certification period; 6 (six) CE hours must be in Prevention Ethics. The 6 hours used towards re-certification shall be of Clinical Supervisor training, which may be part of the 40 hours used for CCS and CADAC recertification. Continuing education hours accepted as 50% online courses and 25% trainer courses. Recertification Fee: $130 (Optional: IC&RC International Certificate Fee = $25)

3 New Mexico Credentialing Board for Behavioral Health Professionals P.O. Box Albuquerque, NM Certified Clinical Supervisor Application for Professional Certification The entire application must be printed legibly or typed Name First Initial Last Name (as it will appear on the Certificate) SS#: - - Date of Birth: Gender M F Home Address: City State Zip Home Phone Mobile Phone Home Primary Employer Address City State Zip Phone Fax Work Position Title Supervisor Name Send mail to (please circle preference): Home Work Send to (please circle preference): Home Work Ethnicity: Native American Asian American Black American Anglo Hispanic Other (Used for statistical use only) Education (circle highest level) GED High school Associates Bachelor s Master s PhD Professional Affiliations and Current Licenses

4 Alcohol and Drug Abuse/Treatment Work Experience (Begin with Current Employment) Facility/ Address Dates of Employment: Phone (From M0/YR) (To M0/YR) Title/Position: Duties: Alcohol and Drug Abuse/Treatment Work Experience Facility/ Address Dates of Employment: Phone (From M0/YR) (To M0/YR) Title/Position: Duties: Alcohol and Drug Abuse/Treatment Work Experience Facility/ Address Dates of Employment: Phone (From M0/YR) (To M0/YR) Title/Position: Duties:

5 Other Experience in Behavioral Health Counseling Field (Attach Additional Sheet if Necessary). Facility/ Address Dates of Employment: Phone (From M0/YR) (To M0/YR) Title/Position: Duties: Other Experience in Behavioral Health Counseling Field (Attach Additional Sheet if Necessary). Facility/ Address Dates of Employment: Phone (From M0/YR) (To M0/YR) Title/Position: Duties: Peer References (Professional Colleagues). Persons submitting letters must be sent directly to the Certification Board. Name Facility Address Phone Name Facility Address Phone Professional Reference (Outside Agency) Name Facility Address Phone I hereby attest that all information provided in this application is true and valid to the best of my knowledge. Printed Name SIGNATURE DATE

6 Employment Verification Form Date: Name of Applicant: Agency: Agency Address: Agency Phone #: Title/Position: Date of Employment: to Major Duties: Percentage of time spent in activities related to Management and Administration: Setting goals for the program, negotiation contract and/or third party billing reimbursement, grant writing, creating of revising program policies and procedures, setting budget guidelines, public speaking. Percentage of time spent in activities related to Case Management and Training: Case staffing, counselor skill development and guidance sessions performed one to one or in a group less than four, workshops, group discussions, in service training, lectures. Supervised practicum training hours completed under your supervision: Supervisor Name Supervisor Signature Title

7 Code of Ethics for Substance Abuse Clinical Supervisors I Code of Ethics This code of ethics applies to Alcohol, Tobacco and Other Drugs (ATOD) Substance Abuse Professionals who are credentialed as Certified Clinical Supervisors (ATOD/CCS) and applies to their conduct during the performance of their clinical duties as supervisors. II Supervision Supervision is a disciplined and defined clinical activity. It has a parallel, but linked relationship to teaching, consulting, administering and researching. It is a necessary, significant and meaningful aspect of the delivery of competent, humane, ethical and appropriate services to clients/consumers. III. Rules of Conduct These ethics constitute the standards an ATOD/CCS should maintain. These ethics shall be used as an aid in resolving an ambiguity, which may arise in the application and interpretation of these rules. IV Competence An ATOD/CCS shall limit practice to areas of competence in which proficiency has been gained through education or documentable experience or through the awarding of a reciprocal professional certification of licensure. An ATOD/CCS 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/CCS shall aggressively seek out consultation with other professionals when called on to supervise counseling situations outside their realm of competence. An ATOD/CCS will refer supervisees to other competent staff when they are unable to provide adequate supervisory guidance to the supervisee. V. Client Welfare and Rights The primary obligation of an ATOD/CCS is to train substance abuse counselors so that they respect the integrity and promote the welfare of their clients. ATOD/CCS should have supervisees inform clients that they are supervised and that details of their treatment can and will 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/CCS should make supervisees aware of client s rights, including protecting clients rights to privacy and confidentiality in the counseling relationship and the information resulting form it. Clients also should 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, and 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 by the client. An ATOD/CCS is responsible for monitoring the professional actions of their supervisees as well as their failure to take appropriate action. An ATOD/CCS is responsible for the presentation of adequate training for all supervisees in the area of transference, dual relationships, cultural sensitivity and professional deportment. VI. Professional Behavior Due to the unique scope of practice substance abuse counselors provide, ATOD/CCS must monitor the following behaviors of their staff and themselves. 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 mood-altering substance when engaged in professional pursuits. C. The conducting of intimate, personal and/or business relationship of any kind with any patient or their families. This applies to all clients. A supervisee should have all relationships of this kind reviewed. An ATOD/CCS should consult with an objective peer when this issue is raised.

8 D. ATOD/CCS Counselors who are members of Alcoholics Anonymous, Cocaine Anonymous, Narcotics Anonymous, Al Anon, etc., shall not become a sponsor to any active, discharged patient or family member. E. ATOD/CCS Counselors are in violation of this code and are subject to revocation or other appropriate action if after certification they: 1. Are convicted of any felony. 2. Are convicted of a misdemeanor related to their qualifications or functions. 3. Engage in conduct, which could lead to conviction of a felony or misdemeanor related to their qualifications or functions. 4. Are expelled from or disciplined by other professional organizations. 5. Have their certification suspended, revoked, or otherwise disciplined by regulatory bodies. 6. Shall refuse to seek treatment for alcohol/drug abuse, mental/emotional problems, or physical health problems that interfere with professional functioning. 7. Fail to cooperate at any point of an ethical complaint investigation. F. ATOD/CCS respects the dignity and protects the welfare of participants in research and is aware of regulations and professional standard governing the conduct of research including informed consent. G. ATOD/CCS Counselors make financial arrangements with clients, third party payer and supervisees that are understandable and conform to accepted professional practices. Clinical supervisors will not disclose any fees to clients and supervisees at the beginning of services and represent facts truthfully to clients, third party payers and supervisees regarding services rendered. H. ATOD/CCS Counselors accurately represent their competence, education, training and experience relevant to their practice as ATOD/CCS and clinical experience. ATOD/CCS assure that advertisements and publications in any media (such as directories, announcements, business cards, newspapers, radio, television and facsimiles) convey information that is necessary for the public to make an appropriate selection of professional services. VVI. Supervisory Role Inherent and integral to the role of supervisor are responsibilities for monitoring of client welfare, insuring compliance with relevant legal and professional standards of services 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. A. An ATOD/CCS must maintain professional decorum and standards. Unprofessional behavior outlined in item VI above will not be tolerated. B. An ATOD/CCS should obtain ongoing training in supervision. C. An ATOD/CCS should pursue professional and personal continuing education activities to maintain their ATOD/CCS credential and to improve their supervisory skills. Competency in the Four Performance Domains of ATOD Clinical Supervision must be maintained. D. An ATOD/CCS should 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. E. An ATOD/CCS should not exploit, but 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. F. Procedures for contacting the supervisor, or an alternative supervisor to assist in handling crisis situations should be established and communicated to supervisees. G. Supervision is maintained through regular face-to-face meetings with supervisee in group or individual sessions. H. Actual work samples via audio, counselor report, video or observation should be part of the regularly scheduled supervision process.

9 I. An ATOD/CCS should provide supervisees with ongoing feedback on their performance. J. An ATOD/CCS 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 supervisees should know the limitations placed on the ATOD/CCS and the supervisor should share supervision when appropriate. K. An ATOD/CCS should not sexually harass make sexual advances or participate in any form of sexual contact with supervisees. Supervisors should not engage in any form of social contact or interaction, which would compromise the supervisor-supervisees relationship. Dual relationship (including outside consults, partnerships, nepotism, etc.) with supervisees that might impair the supervisor s objectivity and professional judgment should be avoided and/or the supervisory relationship terminated. L. ATOD/CCS should not use the supervision process to further personal, religious, political, business or interests. M. ATOD/CCS should not endorse any treatment that would harm a client either physically or psychologically and should ensure the professional quality of the program on which their supervisees participate. N. An ATOD/CCS should not establish a psychotherapeutic relationship as a substitute for supervision. Personal issues should be addressed in supervision only in terms of the impact of these issues on clients and on professional functioning. O. An ATOD/CCS should never supervise past or current clients who are staff or their families. P. An ATOD/CCS should model appropriate use of supervision themselves for problem solving and practice reviewing. Q. An ATOD/CCS must be straight forward with supervisees about observed professional and clinical limitations of the supervisee. These concerns must be clearly documented and shared with the supervisee. R. An ATOD/CCS should not endorse a supervisee for certification or credentialing if the supervisor has documented proof of impairment or professional limitations that would interfere with the performance of counseling duties in a competent and ethical manner. The presence of any impairment should begin with a process of feedback and remediation 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/CCS should incorporate the principles of informed consent and participation; clarity of requirements, expectation; roles and rules; and due process and appeal; into the establishment of policies related to progressive discipline. T. An ATOD/CCS must be able to integrate the Core Functions of Substance Abuse Clinical Competency into their theoretical and supervisory approach. A clear understanding of the Global Criteria is essential. U. An ATOD/CCS should be an active participant in quality assurance and peer review V. The supervision provided by an ATOD/CCS 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 or social or economic status. When a supervisor is unable to provide non-judgmental supervision a referral to an appropriate supervisor with a complete explanation of the supervisee must be made. By signing, I attest that I have read the above Ethical Standards and agree to abide by them. APPLICANT SIGNATURE DATE WITNESS

10 STATEMENT OF UNDERSTANDING AUTHORIZATION AND RELEASE I hereby apply for certification to the New Mexico Credentialing Board for Behavioral Health Professionals. I understand that approval of my application depends upon my successfully completing the assessment of competencies as established by the Board, including submission of all required references and sitting for an examination if required. I also understand that for research and statistical purposes only, the data from this application may be used in a non-identifying manner. I hereby authorize the New Mexico Credentialing Board for Behavioral Health Professionals, to make any inquiry of any agency, facility, or organization or individual for any and all additional information, which might be necessary to fully and properly evaluate my application for CS. I hereby release and hold harmless the New Mexico Credentialing Board for Behavioral Health Professionals, its Board of Executive Officers, its employees, servants, and agents from any and all manner of suits, actions, claims, and judgments which might arise from such efforts to further document the statements and claims I have made in this application or in the processing of consideration of same. I further acknowledge, understand, and agree that any falsification or misrepresentation of information by me or others regarding my experience and/or qualifications will be sufficient reason for denial of my application or for withdrawal of certification later. Printed Name SIGNATURE DATE

11 New Mexico Credentialing Board for Behavioral Health Professionals P.O. Box Albuquerque, NM CLINICAL SUPERVISOR EVALUATION FORM*CONFIDENTIAL* Dear Colleague You have been selected to be one of the professional references by a candidate seeking certification as a Clinical Supervisor. The New Mexico Credentialing Board for Behavioral Health Professionals is established to certify substance abuse counselors, clinical supervisors, and prevention professionals in New Mexico. Certification is based on professional experience, training requirements, appropriate supervision, references, and the successful completion of examination. There are a number of certified counselors who, by virtue of advanced training and/or experience, have the skills, knowledge, and desire to train and supervise other substance abuse counselors. To identify these counselors and to provide a standard by which to measure the quality of clinical supervision received within the field, NMCBBHP has clinical supervision requirements that meet the International Certification Reciprocity Consortium/ Alcohol and Other Drug Abuse (IC&RC) standards for reciprocity of Certified Clinical Supervisors. Clinical Supervision as a specific aspect of staff development dealing with clinical skills and competencies for persons providing counseling. The structure for supervision is commonly one to one and/or small groups on a regular basis. The methods used are intensive case review and discussion, utilizing direct and indirect observation of counselor s clinical work. A primary purpose of clinical supervision is to ensure skill development evidence in quality patient/client care. Please complete the enclosed reference form for the named applicant. It is most important that you return the completed form to NMCBBHP at the above address. Professional references make up a substantial percentage of an applicant's application approval; it is imperative that each reference be filled out as completely as possible and returned. The Board requests that, in fairness to each applicant, if you cannot knowledgeably complete a minimum of four of the five competency categories, please return the form to the named applicant so s/he can forward it to an alternative reference. Thank you for your time and interest in enhancing the quality of substance abuse supervision and counseling in New Mexico. Release Statement Supervisor: I am in the process of seeking certification from the New Mexico Credentialing Board for Behavioral Health Professionals, as a competent professional Clinical Supervisor. I have identified you as someone in a position to verify my standard of professional performance and/or supervised hours of personal face-to-face substance abuse supervision and counseling. Your documentation will be combined with other documents and assessment to form my application. Your cooperation will assist the board in make a fair and accurate decision. I hereby authorize you to release to the NMCBBHP confidential information required by the Certification board. Name (please print) Signature Date

12 CLINICAL SUPERVISOR REFERENCE FORM Applicants Name Address Phone Number Evaluator Name & Title Program/Agency Name How long have you know the applicant? Relationship to evaluator to applicant (check one) Current Supervisor Colleague Co-worker Other (please specify) INSTRUCTIONS: Please read the description of the various experience and skills outline below. Using the rating scale (0-5) shown below, determine the number that most nearly describes the applicants ability in each category and enter this number in the blank provided to the right of the statement in the column marked Rating. RATING CODE: 0 - Not Known, 1- Inadequate, 2- Needs improvement, 3- Competent, 4- Above Average Competency, 5-Outstanding Skills and Knowledge An advanced knowledge of how substance use disorder relate to and co-occur with other physical, behavioral, cognitive, emotional, socio-cultural, and economic aspects of medical, mental and emotional disorders. An operational experience with a variety of treatment approaches used in the field of substance use disorders. An ability to deal effectively with supervisee s psychodynamics as they relate to his/her work with clients A sufficient knowledge of organizational administration to provide adequate supervision to an addiction counselor Knowledge of the professional development needs of the addiction counselor and awareness of available resources Rating CHECK ONE: I recommend this applicant for certification/credentialing at the Clinical Supervisor level. I have some reservations in recommending this applicant: Total Rating I do not recommend this applicant for certification. Evaluator s Signature: Date

13 SUPERVISED PRACTICAL TRAINING SUMMARY: Supervised Practical Training in the Clinical Supervision Functions Supervised Practical Training includes activities designed to provide training of specific performance domains. These activities are monitored by supervisory personnel who provide timely positive and negative feedback to assist the Clinical Supervisor in this learning process. All training hours must be supervised. A recommended ratio is one hour of supervision (face-to-face individually or in a group) to 6 hours of practical experience. (Copies of this form may be submitted by more than one supervisor.) Types of Training (Please check): On-the-Job Training Training Program Internship FUNCTIONS 1. Assessment/Evaluation DATE COMPLETED NUMBER OF HOURS AGENCY OR SUPERVISOR (S) 2. Counselor Development 3. Management/Administration 4. Professional Responsibilities TOTAL NUMBER OF HOURS NOTE: Required 30 hours for Clinical Supervision Certification. Each function should be no less than 6 hours per Core Function. Print Supervisor Name Supervisor s Signature Date Evaluation: Satisfactory/Not satisfactory if mailed in: Name of Applicant: If unable to document prior practicum: In your own words, please describe your supervised practicum training. Include who trained you and how they trained you. Be sure to include any supervised practical training you received when and if you changed jobs. Use back of page or 2 nd sheet if needed.

14 TRAINING SUMMARY FORM: Thirty (30) hours of didactic training in clinical supervision. This must include a minimum of six (6) of education in each of the performance domains of the current IC&RC/AODA role delineation study. Education must be specifically related to the knowledge and skills necessary to perform the tasks with IC7RC/AODA following performance domains: Assessment/Evaluation, Counselor Development, Management and/or Administration, and Professional Responsibilities. Please list the number of training hours and attach all supporting documentation including copies certificates of attendance for all training and education events. Copies of this form can be made if needed. COURSE/TITLE DATE TRAINING HOURS Note: Only training hours documented/received within the past five (5) years, prior to the date of submitting your application packet, will be accepted. TOTAL