Criteria for Certified Substance Abuse Counselor II (CSAC II)

Transcription

1 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (FAX) Jefferson City, MO Criteria for Certified Substance Abuse Counselor II (CSAC II) I. Criteria for those with an applicable Masters Degree Applicable Masters Degree 2000 Hours of applicable work experience within the last 10 years 300 Hours of a Supervised Practicum in the IC&RC 12 Core Functions Signed Competency Rating Form from a Board qualified supervisor 270 Contact Hours of Education to include the following: 6 Live substance abuse ethics hours (not from online or home study) 20 Hours obtained in last 12 months Pass IC&RC International AODA Examination if not upgrading from CSAC I II. III. Criteria for those with an applicable Bachelors Degree Applicable Bachelors Degree 4000 Hours of applicable work experience within the last 10 years 300 Hours of a Supervised Practicum in the IC&RC 12 Core Functions Signed Competency Rating Form from a Board qualified supervisor 270 Contact Hours of Education to include the following: 6 Live substance abuse ethics hours (not from online or home study) 20 Hours obtained in last 12 months Pass IC&RC International AODA Examination if not upgrading from CSAC I Criteria for those with an applicable Associates Degree Applicable Associates Degree 5000 Hours of applicable work experience within the last 10 years 300 Hours of a Supervised Practicum in the IC&RC12 Core Functions Signed Competency Rating Form from a Board qualified Supervisor 270 Contact Hours of Education to include the following: 6 Live substance abuse ethics hours (not from online or home study) 20 Hours obtained in last 12 months Pass IC&RC International AODA Examination if not upgrading from CSAC I criteria continued on next page Revised 1/10 CSAC II (AODA) Application 1

2 IV. Criteria for those with a High School Diploma/GED High School Diploma/GED 6000 Hours of applicable work experience within the last 10 years 300 Hours of a Supervised Practicum in the IC&RC 12 Core Functions Signed Competency Rating Form from a Board qualified supervisor 270 Contact Hours of Education to include the following: 6 Live substance abuse ethics hours (not from online or home study) 20 Hours obtained in last 12 months Pass IC&RC International AODA Examination if not upgrading from CSAC I APPLICABLE DEGREES (A degree must be from a college or university found in the US Dept. of Education s database of accredited schools. The database can be found at 1. Psychology 4. Sociology 7. Nursing 2. Social Work 5. Chemical Dependency 8. Human Services 3. Criminal Justice 6. Counseling 9. Art Therapy *If your Degree is in an area other than the 9 listed above but you feel it is applicable, please contact the MSAPCB office at to discuss. Revised 1/10 CSAC II (AODA) Application 2

3 DEFINITIONS A. CONTACT HOURS of EDUCATION/TRAINING is defined as workshops, seminars, institutes, accredited college/university courses, home study or on-line courses as pre-approved by the MSAPCB and inservices. One (1) contact hour of education is equal to sixty (60) minutes of continuous instruction. 15 contact hours are given for each college credit. Therefore, a college course of three (3) credits is equal to 45 contact hours. In order to be considered a valid training experience for the purpose of credentialing, education/trainings must be related to the knowledge and skill base associated with the 12 counselor core functions: screening, intake, orientation, assessment, treatment planning, counseling, case management, crisis intervention, client education, referral, reporting and record keeping, and consultation. All education taking place outside the applicant's place of employment must be documented through proof of attendance including original, official transcripts (not issued to the student or copied) from an accredited college, letters and/or certificates of completion. Supporting documentation in the form of brochures, flyers, syllabus, course description, etc. may also be required to review content for acceptability. All education taking place within the applicant's place of employment must be documented by title, date and length of presentation, as well as the name and title of presenter. The training must be verified by the employee's supervisor who attests the training took place and the employee was a participant in the entire training. B. EMPLOYMENT or WORK EXPERIENCE is defined as supervised work experience in a substance abuse treatment position with job duties that assist clients in the recovery process by performing the 12 core functions. Experience as a volunteer, intern and/or payment of a stipend qualifies as work experience if the same work is performed that a paid employee would perform. All qualifying employment experience must have been accrued during the ten (10) years immediately prior to application being made. The maximum hours that can be accrued are one hundred and sixty seven (167) per month or two thousand (2,000) per year. Employment experience must be verified by an employment verification form from the agency(s) in which the applicant has been employed. C. SUPERVISED PRACTICUM IN THE 12 CORE FUNCTIONS is defined as performance of the 12 counselor core functions while under supervision. Supervision may be provided by any CSAC II, CASAC, CCJP, CCDP, CCDP-D, RSAP, RSAP-P, LPC, LCSW, or Licensed Psychologist who has attended the MSAPCB 3 Day Clinical Supervision Training. The supervision of the 12 core functions may take place within an academic setting and/or within a supervised work setting. The goal is to receive supervised experience in all of the 12 core functions. Applicants must complete a minimum of 10 hours performing each of the 12 core functions with a total supervised practicum of 300 hours. Revised 1/10 CSAC II (AODA) Application 3

4 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (FAX) Jefferson City, MO Application Instructions: 1. Requirements to receive this credential are subject to change without notice. Please make sure you are submitting the most recent application packet. If you are unsure, contact the MSAPCB office. 2. The application must be typed or neatly printed. 3. The application must be submitted at least FOUR months prior to the date the applicant desires to take the exam. An exam schedule is included with this packet. 4. Please keep a copy of all materials submitted for your records. 5. FEES: The total CSAC II Fee for a new applicant taking the IC&RC AODA written exam in Jefferson City is $ or $ if you are taking the IC&RC AODA computer based exam at a participating college or university in the state. (This includes the application packet, processing, background screening, and first time test fees) The total CSAC II Fee for someone upgrading from RASAC I/II is $ for the IC&RC AODA written exam or $ for the IC&RC AODA computer based exam. (This includes the application packet, processing, background screening, and first time test fees) The total CSAC II Fee for someone upgrading from CSAC I is $ (This includes the application packet, processing, and background screening fees) You may pay by check, money order, or by providing credit card information on page 7 of this application packet. 6. Please be advised that should your application be reviewed and additional information is requested, you will have 90 days to provide the requested information. Failure to do so will result in your application expiring without being approved. 7. All fees are non refundable. If your application is denied or expires, fees will not be refunded. 8. If your application is denied, you may contact the MSAPCB office staff for instructions on how to appeal the denial of your application. 9. All materials submitted to the MSAPCB office become property of the MSAPCB. 10. The applicant must currently reside and/or be employed in the State of Missouri at least 51% of the time. The only exception to this is applicants living and working in a state that is not a member of the International Certification and Reciprocity Consortium. 11. Please remember that it is your responsibility to keep the MSAPCB office informed of any personal informational changes such as address and phone number changes. If you fail to notify us of changes, you will be responsible for any material that is mailed to the wrong address and will have to pay a fee to have the material sent again. Special Instructions For Those Applicants Upgrading 1. Your application is a continuation from your previous application(s). Therefore, you do not need to submit duplicate information from previous applications such as transcripts, training certificates sent with previous applications, etc. However, you must completely fill out the application packet. Revised 1/10 CSAC II (AODA) Application 4

5 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (FAX) Jefferson City, MO Useful Information: 1. If at any time during the application process, a question arises about an applicant s moral character, reputation for honesty, integrity, or professionalism, the Board may either deny the application at that time or place the application on hold until an investigation has been done and a decision made regarding the question brought up. 2. Once your application has been accepted and has final approval, you will receive an entrance letter to the exam approximately two weeks prior to the exam date. This letter will provide you with the test information. 3. You will also receive a Candidate Guide prior to the test. This guide provides you sample questions for the exam. In addition, additional study materials can be purchased. The agencies that sell study guides are listed on our web site under the items for sale link. The exam you will be taking is called the AODA Exam. 4. The CSAC II credential is a reciprocal credential with other IC&RC member boards that offer this credential. You can contact the MSAPCB office for more information on reciprocity. Computer Based Testing Information: 1. Starting with the March 2010 Exam cycle, testing candidates have a choice between taking a written exam in Jefferson City or a computer based exam in various locations around the state. These locations include Cape Girardeau, Columbia, Kansas City, Kirksville, Park Hills, Rolla, and Springfield. 2. You will notice under the instructions #5 on page 4 of the application packet that the application fee for the IC&RC AODA computer based test is higher. This is due to a higher cost charged to the MSAPCB for the IC&RC AODA computer based test. However, an applicant should be able to offset the higher cost by taking the exam in a location near them instead of traveling to Jefferson City. 3. An applicant that chooses computer based testing will receive specific instructions from us on how to complete the exam once the application packet is approved. However, here is basic information to help an applicant make a decision regarding computer based testing: A. As mentioned in #1 above, there are 7 computer based testing sites in Missouri. Each of these sites is a computer testing lab at a university or college. B. You will have a two-week window to take your testing letter and photo id to the testing lab and complete the exam. C. Upon completing the IC&RC AODA computer based exam, you will receive immediate preliminary results. These will not be official results until you receive a letter and score from the MSAPCB in the mail approximately 4 weeks after the exam date, however, the preliminary score should be accurate. 4. On page 34 of this application, the testing dates are listed for the next year. Please note that the dates listed are for the written exam in Jefferson City. Applicants taking the IC&RC AODA computer based exam will have the two weeks after the written exam to take the computer based exam. Please also note that the written exam is only given in March, June, and September while the IC&RC AODA computer based exam is available in March, June, September, and December. 5. If you have any specific questions or concerns in trying to decide between taking the written or computer based exam, please feel free to contact us for answers to your questions or concerns. Revised 1/10 CSAC II (AODA) Application 5

6 Important Notice To Applicants According to Missouri Substance Abuse Professional Credentialing Board (MSAPCB) Policies and Procedures, the following rules apply to those seeking a MSAPCB credential. 1. No individual currently under any type of court supervision can apply for a MSAPCB credential. Please wait until you are completely free from court supervision before applying. 2. The following items disqualify an individual from ever being credentialed with the MSAPCB: A. Is listed on the Department of Mental Health disqualification registry B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept. of Social Services C. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of the following crimes. The crimes listed will only disqualify an applicant if the crime was a felony. a. 1 st /2nd degree murder aa. Failure to report abuse and neglect to DSS b. Voluntary manslaughter bb. Any equivalent felony offense c. Involuntary manslaughter cc. Forcible sodomy d. 1 st /2nd degree assault dd. Deviate sexual assault e. Assault while on school property ee. Sexual abuse f. Unlawful endangerment of another ff. Abuse of a child g. Sexual assault gg. 1 st /2 nd degree pharmacy robbery h. Tampering with a judicial officer hh. Arson in the 1 st /2 nd degree i. Kidnapping ii. Incest j. Felonious restraint jj. Causing catastrophe k. False imprisonment kk. 1 st degree burglary l. Interference with custody m. Parental kidnapping n. Child abduction o. Elder abuse in 1 st /2nd degree p. Harassment q. Stalking r. Forcible rape s. 1 st /2nd degree statutory rape t. 1 st /2 nd degree assault of a law enforcement officer u. 1 st /2 nd degree statutory sodomy v. 1 st /2 nd degree child molestation w. 1 st degree sexual misconduct x. Endangering the welfare of a child y. Robbery in the 1 st /2 nd degree z. Felony count of invasion of privacy D. Any crime against a minor not listed above 3. If an individual has applied for and been given an exemption from the Department of Mental Health, the individual may apply for a MSAPCB credential. Please send in proof of exemption with your application. Revised 1/10 CSAC II (AODA) Application 6

7 APPLICATION FOR Certified Substance Abuse Counselor II (CSAC II) Appropriate fee must be submitted with application. MISSOURI SUBSTANCE ABUSE PROFESSIONAL CREDENTIALING BOARD P.O. BOX 1250 JEFFERSON CITY, MISSOURI TELEPHONE: (573) FAX: (573) WEB SITE: Please Mark Credit Card Type: 1. Visa 2. MC 3. Discover CC Expiration Date: / Credit Card #: Revised 1/10 CSAC II (AODA) Application 7

8 THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY All Applications Become the Property of MSAPCB Please check if you are: New Applicant Upgrade Applicant Please check one: Written Exam Computer Based Exam If wanting to take the Computer Based Exam, please circle the exam location site: Cape Girardeau Columbia Kansas City Kirksville Park Hills Rolla Springfield Applicant s Name: First Middle Last Sirname Maiden Other Names Used Current Home Address: Street/PO Box Apt. # City State Zip County Home Telephone: / SSN: - - Work Telephone: / Cell Number: / Address: OPTIONAL RESEARCH INFORMATION SEX: M F AGE RACE / / BIRTH DATE EXPERIENCE IN SUBSTANCE ABUSE TREATMENT FIELD 0-5 years 6-10 years 11years & Over CURRENT SALARY $0-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$44,999 $45,000-$54,999 $55,000 & Over Are you currently or have you been credentialed or licensed as a Substance Abuse Professional by any other state or organization? Yes No If yes, which state/organization and when? What is the type of credential/license held with the other state/organization? Have you ever been ARRESTED and/or CONVICTED of a felony? Yes No If yes, please go to the website, print off the Felony Offense Form, fill out the form and submit with your application. If you were convicted of a felony listed under 2C on page 6 of this application, you may not apply for this credential. Have you ever knowingly been contacted by a Division of Family Services employee regarding a CHILD ABUSE and/or CHILD NEGLECT incident involving you? Yes No If yes, please go to the website, print off the Child Abuse/Neglect Statement, fill out the form and submit with your application. In addition, please contact the Division of Family Services at and request a report of the incident to include with this application. Revised 1/10 CSAC II (AODA) Application 8

9 Education/Degree Information Name of High School Dates of Attendance from to Did you graduate? Location of High School G.E.D Date / / Where Issued College and University (undergraduate, graduate, professional) NAME AND LOCATION FROM TO TOTAL SEMESTER MO YR MO YR HOURS MAJOR SUBJECTS DEGREE AND DATE RECEIVED AND/OR # OF CREDIT HOURS Name Location Name Location Name Location Please have official transcript(s) of any applicable course work to be evaluated for the education requirement sent directly to the MSAPCB Board office. Student copies or photocopies will not be accepted. Revised 1/10 CSAC II (AODA) Application 9

10 APPLICABLE WORK EXPERIENCE Describe ONLY your applicable Work Experience below, beginning with your most recent position. If you have held more than one position with an organization, please list each position separately. Make additional copies of this page if necessary to document all applicable work experience. Work experience will be prorated if not working full time in an applicable position. Final determination of the acceptability of work experience shall be at the discretion of the MSAPCB. 1. Where Do You Currently Work? Do you currently work in a CSTAR Program? YES NO Name of Employer: Mailing Address of Employer Street City State Zip Code County Name & Title of Immediate Supervisor: Your Business Phone: Area Code/Telephone Number Extension Fax # Area Code/Telephone Number Your Job Title: 2. Where Did You Work Prior To #1 Above Name of Employer: Dates of Employment (Month/Day/Year): From: To: Is this a full-time paid position? (2,000 hrs. = 1 year) hrs./wk. paid Name & Title of Immediate Supervisor: Mailing Address of Employer Street City State Zip Code County Your Job Title: 3. Where Did You Work Prior To #2 Above? Name of Employer: Dates of Employment (Month/Day/Year): From: To: Is this a full-time paid position? (2,000 hrs. = 1 year) hrs./wk. paid Name & Title of Immediate Supervisor: Mailing Address of Employer Street City State Zip Code County Your Job Title: Dates of Employment (Month/Day/Year): From: To: Is this a full-time paid position? (2,000 hrs. = 1 year) hrs./wk. Paid Revised 1/10 CSAC II (AODA) Application 10

11 TRAININGS/EDUCATIONAL HOURS Following are the number of educational hours needed for the CSAC II: 270 Hours Total 6 Hours of Live substance abuse ethics (not from online or home study) 20 Hours obtained in last 12 months In the space below, chronologically list all applicable trainings, workshops, summer institutes, college coursework, etc. beginning with the most recent training. Number of Date Title Contact Hours PLEASE BE SURE TO SUBMIT CERTIFICATES OF ATTENDANCE AND LETTERS OF COMPLETION FOR EACH TRAINING AS LISTED ABOVE. INSERVICE HOURS MUST BE SIGNED BY SUPERVISOR OR TRAINING COORDINATOR IN YOUR AGENCY. Revised 1/10 CSAC II (AODA) Application 11

12 Additional Space For Chronologically Listed Training Number of Date Title Contact Hours PLEASE BE SURE TO SUBMIT CERTIFICATES OF ATTENDANCE AND LETTERS OF COMPLETION FOR EACH TRAINING AS LISTED ABOVE. INSERVICE HOURS MUST BE SIGNED BY SUPERVISOR OR TRAINING COORDINATOR IN YOUR AGENCY. Revised 1/10 CSAC II (AODA) Application 12

13 Introduction MISSOURI SUBSTANCE ABUSE PROFESSIONAL CREDENTIALING BOARD Code of Ethical Practice and Professional Conduct This document is the foundation for standards which will enable the credentialed professional to measure the propriety of his or her conduct in dealing with clients, other professionals and other members of the community. All professionals credentialed by MSAPCB are expected to thoroughly familiarize themselves with the Code of Ethical Practice and Professional Conduct. The Board is committed to investigate and sanction those who fail to abide by its standards. Principles: Principle 1: Responsibility to Clients Principle 2: Counseling Relationship Principle 3: Legal and Moral Standards Principle 4: Diversity Principle 5: Professional Competence and Integrity Principle 6: Compliance with the Law Principle 7: Cooperation with the Board Principle 1: Responsibility to Clients Informed Consent: Clients have the right to be informed of their rights and responsibilities as they relate to the counseling process. Professionals assume the responsibility of informing clients, in language appropriate to the client, how information obtained from assessments will be used in their treatment. Further, clients also have the right to obtain clear information about their case records; treatment plans, discharge summaries and recommendations for aftercare. Clients have the right to expect confidentiality in the counseling relationship and be informed of exceptions to confidentiality. Professionals shall inform clients of their right to refuse any recommended services and the consequence(s) for their refusal. If a client is unable to exercise their rights, Professionals will act in the client s best interest. Principle 2: Counseling Relationship General respect and caring: MSAPCB Professionals provide an appropriate setting for clinical work to protect the client from harm. Professionals make every effort to respect the dignity and protect the welfare of each client under their care and shall show respect for each client and colleague by maintaining an objective professional relationship at all times. Any activity that results in exploitation of clients for personal gain be it sexual, financial or social will be avoided. Professionals avoid fostering dependent counseling relationships and refrain from imposing their values on clients. Revised 1/10 CSAC II (AODA) Application 13

14 Professionals will remain aware of their own skills and limitations and will not attempt to counsel or advise clients on matters outside their area of expertise. When it is in the best interest of the client, Professionals will release or refer the client to another program or professional. The Professional is responsible for making appropriate arrangements for the continuation of treatment, during interruptions such as vacations and following termination of the counseling relationship. Prior to entering into a counseling relationship, the Professional will clearly explain to the client, the financial arrangements including the use of collection agencies or legal measures for nonpayment. Dual Relationships: Professionals shall make every effort to avoid dual relationships with clients that may include, but are not limited to: familial; social; financial; business; or other types of close personal relationships with clients. It is the Professionals responsibility to refer the client to another professional, if possible, when a dual relationship exists. When a dual relationship cannot be avoided, Professionals take appropriate professional precautions to ensure that judgment is not impaired and no exploitation occurs. Professionals do not accept superiors or subordinates with whom they have administrative, supervisory or evaluative relationships as clients. Multiple Clients: If a Professional provides counseling services to two or more persons who have a relationship (such as husband and wife, or parents and children), the Professional will identify the individual considered to be the primary client(s). If it becomes apparent that the Professional may be called upon to perform potentially conflicting roles, they clarify, adjust, or withdraw from the roles appropriately. Conflict of Interest: If a client is receiving services from another mental health professional, the Professional will, with informed client consent, inform the professional persons already involved and develop clear agreements to avoid confusion and conflict for the client. Principle 3: Legal and Moral Standards Confidentiality: Professionals consider their clients right to privacy to be of paramount importance and avoid illegal disclosures of confidential information. The Professional adheres to all federal, state, and local laws regarding confidentiality. Clients are informed of the limitations of confidentiality and identify foreseeable situations in which confidentiality might be breached. Professionals make every effort to ensure that the privacy and confidentiality of clients is maintained by subordinates including employees, supervisees, clerical assistants, and volunteers. Records: Professionals maintain records necessary for rendering counseling services to their clients as required by laws, regulations, or agency or institutional procedures. The Professional is responsible for securing the safety and confidentiality of any counseling records they create, maintain, transfer, or destroy in whatever forms the record is produced. This applies to records which are written, taped, computerized, or stored in any other medium. Revised 1/10 CSAC II (AODA) Application 14

15 Professionals acknowledge counseling records are kept for the benefit of clients. Consequently, access is provided only when requested by competent clients and when it is determined that the records contain information that is not considered to be misleading or detrimental to the client. When the records involve multiple clients, access to records is limited to those parts of records that do not include confidential information related to another client. The Professional discusses information obtained in clinical, consulting, or observational relationships only in the appropriate settings for professional purposes that are in the client s best interest. Every effort is made to avoid undue invasion of privacy. Fraud-Related Conduct: Professionals provide accurate, honest, and unbiased information when reporting professional evaluations to third parties including courts and health insurance companies. When Professionals provide advice or comment by whatever means, they take reasonable precautions to ensure that the statements are based on appropriate professional counseling literature and practice; and the statements are consistent with MSAPCB s Code of Ethical Practice and Professional Conduct. The Professional does not use their official position to seek or receive unjustified personal gains, sexual favors, unfair advantage, or unearned goods or services. Professionals refrain from charging a client or a third party payer for a service not performed, or submitting an account or charge for services that is false or misleading. Professionals do not publish any advertisement that is false, fraudulent, deceptive or misleading. The Professional also refrains from engaging in fraud, misrepresentation, deception or concealment of material fact when applying for or assisting in securing credentialing or credentialing renewal or taking any examination. Principle 4: Diversity Nondiscrimination: The Professional does not condone or engage in discrimination based on age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. Respecting Differences: Professionals will actively attempt to understand the diverse cultural backgrounds of the clients with whom they work. This includes, but is not limited to, learning how the Professional s cultural/ethnic/racial identity impacts his/her values and beliefs about the counseling process. The Professional should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures. Professionals should have a knowledge base of their client s cultures and be able to demonstrate competence in the provision of services that are sensitive to clients cultures and to differences among people and cultural groups. The Professional should obtain education about and seek to understand, the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sexual orientation, age marital status, religion, and mental or physical disability. Revised 1/10 CSAC II (AODA) Application 15

16 Principle 5: Professional Competence and Integrity Competence and Self-Knowledge: Professionals strive to give precedence to their professional responsibility over personal interests and uphold the dignity and honor of the profession. The Professional shall seek appropriate professional assistance for their personal problems or conflicts that may impair work performance or clinical judgment. Professionals have a responsibility to read, understand, and follow the Code of Ethical Practice and Professional Conduct. Professionals practice only within the boundaries of their competence and avoid practice in specialty areas new to them until they obtain appropriate education, training, and supervised experience. Professionals accept responsibility for their continuing education and professional development as part of their commitment to providing quality care for persons who seek their services. Professionals take responsibility for identifying their values and beliefs and take measures to prevent imposing their values on clients. The Professional makes a commitment to continually review their ethical competence and attend traditional (not online) training session on ethical conduct as determined by MSAPCB. Professionals in private practice take reasonable steps to seek out peer supervision to evaluate their efficacy as counseling professionals. Sexual Misconduct: Professionals do not have any type of sexual intimacies with clients and do not counsel persons with whom they have had a sexual relationship. Professionals do not engage in sexual intimacies with former clients within a minimum of two years after terminating the counseling relationship. Professionals who engage in such relationships after two years have the responsibility to document that such relations did not have an exploitative nature. Professionals do not engage in sexual harassment. Sexual harassment is defined as sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with professional activities or roles, and that either is unwelcome, offensive, or creates a hostile workplace environment. Sexual harassment can consist of a single intense or severe act or multiple persistent or pervasive acts. Do no harm: Professionals refrain from offering or accepting professional services when their physical, mental or emotional problems may pose a risk to clients or others. They are alert to the signs of impairment, seek assistance for problems, and, if necessary, limit, suspend, or terminate their professional responsibilities. The Professional abstains from the non-medical use of any mood altering chemicals while on the job, and will abstain from all illegal substances at all times. Professionals strive to serve as a responsible role model for clients, staff and the community. Revised 1/10 CSAC II (AODA) Application 16

17 Superior/Subordinate Relationships (Clinical Supervision): Clinical Supervisors clearly define and maintain ethical, professional, and social relationship boundaries with their trainees, interns and supervisees. They respect the differential in power that exists between the supervisor and the trainees, interns or supervisees. The Clinical Supervisor explains to the trainees, interns and supervisees the potential for the relationship to become exploitative. Clinical Supervisors do not engage in sexual relationships with trainees, interns or supervisees and do not subject them to sexual harassment. Clinical Supervisors who supervise the counseling services of others take reasonable measures to ensure that counseling services provided to clients are professional. Clinical Supervisors do not endorse trainees, interns or supervisees for credentialing, employment, or completion of an academic or training program if they believe trainees, interns or supervisees are not qualified for the endorsement. Clinical Supervisors take reasonable steps to assist students or supervisees who are not qualified for endorsement to become qualified. Clinical Supervisors clearly state to trainees, interns and supervisees, in advance of training, the levels of competency expected, appraisal methods and timing of evaluations for both didactic and experiential components. Trainees, interns and supervisees are provided with periodic performance appraisal and evaluation feedback throughout the training program. Trainees, interns and supervisees are informed of the ethical responsibilities and standards of the profession and the trainees, interns and supervisee s ethical responsibilities to the profession. Unprofessional Conduct: Professionals refrain from participating in inappropriate conduct not befitting their profession. In the event of an ethics complaint &/or hearing, the Professional s conduct will be measured against accepted standards and practices. Professionals have a responsibility to alert their employers to conditions that may be potentially disruptive or damaging or that may limit their effectiveness. Inter-Professional Relationships: Professionals actively participate in local, state, and national associations that foster the development and improvement of counseling. The Professional shall adhere to a strict policy of respect for the views, actions, and findings of colleagues and members of other professions and programs. Appropriate practices will be used when expressing agreement or disagreement in judgment on such matters. The Professional shall not denigrate other professions nor engage in any false or misleading communications about their own or other professionals abilities, training/experience and ethical conduct. The Professional is respectful of approaches to counseling that differ from her/his own. Professionals know and take into account the traditions and practices of other professional groups with which they work. Professionals select competent staff and assign responsibilities compatible with their skills and experiences. The Professional refuses to participate in an employer s practices which are inconsistent with the ethical standards enumerated in this Code. Principle 6: Compliance with the Law Unlawful conduct: All credentialed professionals are expected to comply with all federal, state, and local laws. Anyone who is convicted of any offense other than a misdemeanor has the obligation to report the conviction to the MSAPCB. The definition of conviction includes: A plea or verdict of guilty or a conviction following an Alford Plea, or any other plea which is treated by the court as a plea of guilty and all the proceedings in which the sentence was deferred or suspended, or the conviction expunged shall be deemed a conviction within the meaning of this section. Revised 1/10 CSAC II (AODA) Application 17

18 Grounds for Discipline: Permitting, aiding, abetting, assisting, hiring or conspiring with an individual to violate or circumvent any of the laws relating to licensure or credentialing under any licensing or credentialing act. Principle 7: Cooperation with the Board The Professional shall cooperate in any investigation conducted pursuant to this Code and shall not interfere with an investigation or a disciplinary proceeding or attempt to prevent a disciplinary proceeding or other legal action form being filed, prosecuted, or completed. Interference attempts may include but are not limited to: The willful misrepresentation of facts before the disciplining authority or its authorized representative; the use of threats or harassment against, or an inducement to, any consumer or witness in an effort to prevent them from providing evidence in a disciplinary proceeding or any other legal action; the use of threats or harassment against, or an inducement to any person in an effort to prevent or attempt to prevent a disciplinary proceeding or other legal action from being filed, prosecuted or completed. Professionals shall report any violation of the Code of Ethical Practice and Professional Conduct. Failure to report a violation may be grounds for discipline. A Professional who has firsthand knowledge of the actions of a respondent or complainant shall cooperate with a MSAPCB complaint investigation or disciplinary proceeding. Failure or an unwillingness to cooperate in a MSAPCB complaint investigation or disciplinary proceeding shall be grounds for disciplinary action. Professionals shall not knowingly file a complaint or provide information to the MSAPCB which they know or should have known is false or misleading. When submitting any information to the Board, the Professional shall comply with any requirements pertaining to the disclosure of consumer information established by the federal or state government. The primary commitment of the Professional is to the health, welfare, and safety of the client. As an advocate for the client, the Professional must take appropriate action to report instances of incompetent, unethical, or illegal practice by other credentialed professionals that places the rights or best interests of the client in jeopardy. Acknowledgments The Missouri Substance Abuse Professional Credentialing Board would like to thank the following agencies/states for their contribution to the preparation of this code: 1. NAADAC 2. Canadian Psychological Association 3. California Association of Addiction Recovery Resources 4. NATTC Curriculum Committee 5. Illinois 6. Hawaii 7. Iowa 8. Connecticut 9. Pennsylvania 10. Arkansas 11. Kansas 12. Arizona Revised 1/10 CSAC II (AODA) Application 18

19 Applicant s Agreement to the Code of Ethical Practice and Professional Conduct I have read the Code of Ethical Practice and Professional Conduct and agree to abide by this code: Signature Date AUTHORIZATION AND RELEASE I hereby certify all of the information given herein is true and complete to the best of my knowledge and belief. I also authorize any relevant investigations, or the release of personal information to the Missouri Substance Abuse Professional Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. I understand falsification of any portion of this application/renewal will result in my being denied credentialing, or revocation of same upon discovery. I further agree to hold the Missouri Substance Abuse Professional Credentialing Board and its Board Members, officers, agents, staff, peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any action that is within the scope and arise out of the performance of their duties which they, or any of them, may take in connection with this application/renewal, the written examination, the grades with respect to any examination, and/or the failure of the MSAPCB to issue me said credential or renewal. This Authorization and Release shall also apply to personal information requested by the Board at any time following credentialing in connection with any investigation concerning allegations that could lead to disciplinary action against me. Signature Date Revised 1/10 CSAC II (AODA) Application 19

20 MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES FAMILY CARE SAFETY REGISTRY WORKER REGISTRATION PLEASE TYPE OR PRINT CLEARLY SECTION A: WORKER TYPE (CHECK ONE BOX ONLY) CHILD CARE WORKER ($9.00) PERSONAL CARE WORKER ($9.00) xx VOLUNTARY REGISTRANT ELDER CARE WORKER ($9.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00) FOSTER PARENT (NO FEE) SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING LAST NAME FIRST NAME MIDDLE NAME MAIDEN AND PRIOR NAMES USED SOCIAL SECURITY NUMBER (ATTACH COPY OF SOCIAL SECURITY CARD) DATE OF BIRTH / / GENDER MALE FEMALE TELEPHONE NO. (OPTIONAL) ( ) MAILING ADDRESS STREET ADDRESS OR POST OFFICE BOX CITY STATE ZIP CODE COUNTY HOME ADDRESS (if different than mailing address) STREET ADDRESS CITY STATE ZIP CODE COUNTY SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE) EMPLOYER NAME CONTACT PERSON PHONE NUMBER ( ) ADDRESS CITY STATE ZIP CODE SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to process this request. Futhermore, I authorized the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in , subsection 1 subdivision (1) and (2), RSMo. For purposes of the FCSR, employment purposes includes direct employer/employee relationships, prospective employer/employee relationships, and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer of information to the FCSR within thirty (30) days of receiving the results of the background screening determination. NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my signature below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds from your account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees. SIGNATURE OF APPLICANT (REQUIRED IN INK) DATE / / IMPORTANT Individuals are required to register one time only. Contact (toll free) if you have questions on how to complete this form Read back of form for instructions and information on registrant notification and appeal rights Send completed registration form, copy of Social Security card and required fee to: Missouri Department of Health and Senior Services Attn: Fee Receipts a copy of your social security card. P.O. Box 570 Jefferson City, MO MO (FP) Send this form in with your application and with Revised 1/10 CSAC II (AODA) Application 20

21 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (Fax) Jefferson City, MO COUNSELOR EMPLOYMENT VERIFICATION FORM An applicant is applying to the MSAPCB for a CSAC II Credential. Please return the completed information within one week of receipt directly to the Board at the address listed above. This form MUST be notarized and MUST HAVE JOB DESCRIPTIONS attached for the position listed below. Please make copies of this sheet and use one sheet for each different job title. Please give a copy of this form to the applicant for their records and future reference. Please feel free to add any additional or clarifying comments on a separate sheet, as this information will be confidential. Employee's Name: Supervisor's Name: Agency: Address: Telephone: Today s Date: Applicant s Job Title: Please make copies of this sheet and use one sheet for each different job title-attach official job descriptions Start Date: Only experience within last 10 years is applicable End Date: If still in position, use date the form is being filled out For each of the following 12 core functions, please list the total number of hours of work experience the applicant completed for each core function while in this position: Screening: Treatment Planning: Client Education: Intake: Counseling: Referral: Orientation: Case Management: Record Keeping: Assessment: Crisis Intervention: Consultation: Total # Hours In All Core Functions: Maximum total number of hours allowed by the MSAPCB is hours per month or 2,000 hours in 12 months Superior's Signature: Title: Signed and sworn to before me this day of, Notary Public: My Commission expires: (NOTARY SEAL) Revised 1/10 CSAC II (AODA) Application 21

22 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (Fax) Jefferson City, MO SUPERVISED PRACTICUM OF THE 12 CORE FUNCTIONS FORM INSTRUCTIONS: On this form document the number of supervised hours performed in each core function. The applicant must have completed a total of 300 hours. The applicant must perform a minimum of 10 hours in each function. The remaining number of hours needed for credentialing can be in any of the functions. This form must be filled out by a Board qualified supervisor (Board Qualified Supervisor includes any CSAC II, CASAC, CCJP, CCDP, CCDP-D, RSAP, RSAP-P, LPC, LCSW, or Licensed Psychologist who has completed the MSAPCB 3 day Clinical Supervision Training. This cannot be an immediate family member) FUNCTIONS Screening - the process by which a client is determined appropriate and eligible for admission to a particular program. Client Intake - the process of collecting client information at the beginning of treatment that is used in assessment of a client for treatment. NUMBER OF HOURS Performed Performed FUNCTIONS Case Management - activities which bring services, agencies, resources or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contracts. Crisis Intervention - those services which respond to client's needs during acute emotional and/or physical distress. NUMBER OF HOURS Performed Performed Client Orientation - individual or group sessions to familiarize clients with program services, expectations and goals. Client Assessment - the process by which a counselor evaluates the intake information collected in order to determine the appropriate services. Treatment Planning - defining areas of problems and needs, establishing long and short term goals, and developing appropriate strategies for reaching these goals Counseling (Individual, Group & Significant Others) - a one-to-one counselor/client process for the purpose of assessing a client's problems and facilitating appropriate changes. Performed Performed Performed Performed Client Education - presenting information with the major goal of increasing the client's knowledge and recognition of significant symptoms and patterns of problematic behavior. Referral - identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available. Record Keeping - charting the results of the assessment and treatment plans; writing reports, progress notes, discharge summaries and other client-related data. Consultation - relating with counselors and other professionals in regard to client treatment (services) to assure comprehensive, quality care for the client Performed Performed Performed Performed Applicant's Name: Name of Supervisor: Credential/License Certificate#: Title: Agency: Clinical Supervision Certificate#: Address: Beginning and Ending Dates the Hours Documented Above Were Supervised: Supervisor's Signature: Today s Date: Total Performed Hours Documented Above: Please return this form directly to MSAPCB, PO Box 1250, Jefferson City, MO Provide a copy of this form to the applicant. Revised 1/10 CSAC II (AODA) Application 22

23 Missouri Substance Abuse Professional Credentialing Board (573) P.O. Box 1250 (573) (Fax) Jefferson City, MO COMPETENCY RATING FORM 1=Understands; 2=Developing; 3=Competent; 4=Skilled; 5=Master INSTRUCTIONS FOR SUPERVISOR: On this form, a board qualified supervisor should rate the competency of the applicant in the 10 listed areas using the rating scale 1-5 given above. For help in determining a rating for a particular area use the competency rating forms found in your clinical supervision manual and/or the TAP 21. (Board Qualified Supervisor includes any CSAC II, CASAC, CCJP, CCDP, CCDP-D, RSAP, RSAP-P, LPC, LCSW, or Licensed Psychologist who has completed the MSAPCB 3 day Clinical Supervision Training. This cannot be an immediate family member) Practice Dimension Rating 1. Clinical Evaluation Screening 2. Clinical Evaluation Assessment 3. Treatment Planning 4. Referral 5. Individual Counseling 6. Group Counseling 7. Family Counseling 8. Client, Family, and Community Education 9. Documentation 10. Professional/Ethical Responsibilities Total Rating Score (Please add the scores together for numbers 1 10 to get a total rating score) Applicant's Name: Name of Supervisor: Credential/License Certificate#: Title: Agency: Clinical Supervision Certificate#: Address: Supervisor's Signature: Today s Date: Please return this form directly to MSAPCB, PO Box 1250, Jefferson City, MO Provide a copy of this form to the applicant. Revised 1/10 CSAC II (AODA) Application 23