Applicatin Packet Credentialed Alchlism and Substance Abuse Cunselr (CASAC) and CASAC Trainee New Yrk State Office f Alchlism & Substance Abuse Services Addictin Services fr Preventin, Treatment, Recvery PDS-11 [September 2014]
TABLE OF CONTENTS Purpse f the Credential... 1 Credentialing Prcess Applicatin... 1 Minimum Qualificatins... 1 Examinatin... 1 Credentialing Optins... 2 Fee Schedule... 3 General Applicatin Instructins... 3 Mailing Address... 3 Part A Applicatin Summary Applicatin Summary Checklist... 4 Applicatin Summary Frm... 5-6 Cann f Ethical Principles... 7 Miscnduct and Other Prhibited Acts... 8 Part B Evaluatin f Ethical Cnduct Evaluatin f Ethical Cnduct Checklist... 9 Requirements... 10 Evaluatin f Ethical Cnduct Frm (make 3 cpies)... 11-12 Part C Wrk Experience Wrk Experience Verificatin Checklist... 13 Apprved Wrk Experience... 14 Academic Degrees... 15 Wrk Experience Verificatin Recrd Frm... 16-17 Part D Educatin and Training Educatin and Training Checklist... 18 Optin Overview... 19 Minimum Requirements... 19 Educatin and Training Sectins... 19-23 Only return the frms (blded) with yur applicatin dcumentatin. Applicatin instructins may be retained fr yur reference thrughut the credentialing prcess.
PURPOSE OF THE CASAC AND CASAC TRAINEE CREDENTIALS The New Yrk State Office f Alchlism and Substance Abuse Services (OASAS) is cmmitted t enhancing the quality f services in New Yrk State thrugh the prfessinal develpment f the alchlism and substance abuse services wrkfrce. T ensure that cunselrs wh prvide direct care in alchlism and substance abuse prgrams are cmpetent and ethical in their wrk and skilled in meeting the needs f tday s sciety, OASAS issues a prfessinal credential -- the Credentialed Alchlism and Substance Abuse Cunselr (CASAC) and the CASAC Trainee -- t individuals wh meet specific eligibility requirements and pass an examinatin. CREDENTIALING PROCESS In rder t becme a CASAC r CASAC Trainee in New Yrk State, yu must: (1) meet specific cmpetency and ethical cnduct requirements; (2) meet specific wrk experience requirements; (3) meet minimum educatin and training requirements; (4) successfully cmplete a criminal backgrund check review; and (5) pass the Internatinal Certificatin and Reciprcity Cnsrtium, Inc. (ICRC) examinatin fr Alchl and Drug Abuse Cunselrs (ADC). Applicatin Upn receipt by the OASAS Credentialing Unit, yur Applicatin will be reviewed t ensure that the minimum eligibility requirements have been satisfied. Based n the findings f this review, yur Applicatin will be determined t be either incmplete r apprved. Please nte that Applicatins are reviewed in the rder they are received and it may take an extended time t prcess due t the high vlume received. If yur Applicatin is determined t be incmplete, yu will be mailed a CASAC Applicatin Review Summary identifying nted deficiencies. If yu are unable t address the identified deficiencies by the end f the five-year perid, yur Applicatin will nt be apprved and yu will nt be issued a CASAC Credential. In rder be cnsidered fr a CASAC in the future, yu will be required t submit a new Applicatin, assciated dcumentatin, and an additinal $100 Applicatin Prcessing Fee. Minimum Qualificatins T apply t becme a CASAC r CASAC Trainee, yu must: be at least 18 years f age; have earned at least a: (1) High Schl Diplma (btained frm institutins recgnized by the New Yrk State Department f Educatin r its equivalent); r (2) General Equivalency Diplma (GED); be prficient in English, including the ability t speak, write, cmprehend rally, and read at a minimum level necessary t perfrm as a credentialed alchlism and substance abuse cunselr; and must live r wrk in New Yrk State at least 51 percent f the time during the five-year applicatin perid. Examinatin The ICRC Alchl and Drug Cunselr (ADC) Exam is ffered n a weekly basis. A candidate may retest nce every 60 days as lng as an active applicatin is n file. Eligibility fr the ADC exam may be met by satisfactrily cmpleting the 350 educatinal hurs. Yu will nt be issued a CASAC certificate until yu have satisfactrily cmpleted the requirement f 6,000 hurs f wrk experience, submissin f the apprpriate evaluatins f cmpetency and ethical cnduct and successful cmpletin f the Criminal Backgrund Check prcess. The Applicatin, assciated instructins, and fees are subject t change withut ntice. PDS-11 [September 2014] NYS OASAS Page 1 f 23
CREDENTIALING OPTIONS Applicatin submissin fr either a CASAC r CASAC Trainee must include the frms and additinal dcumentatin as utlined belw. Yu must select and apply fr ne f the fllwing ptins: Optin 1 - CASAC Trainee EXAM ELIGIBLE Expires in 5 years with an ptin f a 3-year extensin. Part A - Applicatin Summary A cpy f yur highest level f educatin cmpleted (diplma r transcript). A cpy f yur OASAS 350-hur Standardized Certificate f Cmpletin. $100 Applicatin Prcessing Fee (in the frm f a certified check r mney rder). Optin 2 CASAC Trainee NON-EXAM ELIGIBLE Expires in 5 years withut the ptin fr a 3-year extensin. A cpy f yur highest level f educatin cmpleted (diplma r transcript). Minimum f 4,000 hurs f apprved wrk experience r degree substitutin (Part C Frm). Dcumentatin f cmpletin fr 85 clck hurs f educatin and training related t Knwledge f Alchlism and Substance Abuse (Sectin I). Must include a minimum f 4 hurs f training related t tbacc use and nictine dependence. $100 Applicatin Prcessing Fee (in the frm f a certified check r mney rder). Optin 3 CASAC EXAM ELIGIBLE Cmplete applicatin upn initial submissin. Part A - Applicatin Summary A cpy f yur highest level f educatin cmpleted (diplma r transcript). A cpy f yur OASAS 350-hur Standardized Certificate f Cmpletin. Three cmpleted Evaluatins f cmpetency f Ethical Cnduct Frms (Part B Frm). Minimum f 6,000 hurs f supervised experience in an apprved wrk setting as a prvider r supervisr f direct patient services (Part C Frm). $100 Applicatin Prcessing Fee (in the frm f a certified check r mney rder). Successful cmpletin f the ICRC AOD examinatin. It is very imprtant t cnsider the fllwing when chsing yur credentialing ptin: If chsing ptin 2 r 3, yur degree r cllege transcript must verify the apprved human services field majr (see page 15 fr list). The CASAC Trainee certificate serves as dcumentatin that yu are wrking tward becming a CASAC. CASAC Trainees may be cunted tward the Qualified Health Prfessinal (QHP) staffing requirement in specific OASAS-certified chemical dependence treatment prgrams. The CASAC Trainee certificatin will nt authrize yu t be cnsidered a QHP fr any ther purpse than that stated abve. If yu d nt cmplete the credentialing prcess by the expiratin date f yur CASAC Trainee certificate extensin, yu will be required t submit a new Applicatin, assciated dcumentatin and an additinal $100 t becme a CASAC in the future; hwever, yu will nt be eligible fr a CASAC Trainee. Please nte that many f yur questins may be answered n the Frequently Asked Questins page at www.asas.ny.gv/faqs. PDS-11 [September 2014] NYS OASAS Page 2 f 23
FEE SCHEDULE All fees are nn-refundable, regardless f the results f yur criminal backgrund check. Fees must be made payable t NYS OASAS in the frm f a certified check r mney rder. Persnal checks will nt be accepted, will be returned, and will delay prcessing f yur Applicatin. Please d nt send cash. Applicatin Prcessing Fee... $100 Cmputer Based Examinatin Fee....$245 CASAC Trainee Extensin Fee...$100 Yu d nt need t send $100 every time yu submit additinal dcumentatin fr review. The $100 applicatin fee cvers administrative services prvided during the five-year perid that yur applicatin is active. GENERAL APPLICATION INSTRUCTIONS These instructins are intended t guide yu in cmpleting yur Applicatin t becme a CASAC r CASAC Trainee. Please read the fllwing infrmatin befre preparing yur Applicatin. Make a cpy f the Applicatin Packet t use as a wrking draft befre preparing yur Applicatin. After cmpleting the wrking draft, enter the final infrmatin nt the riginal Applicatin. Please print clearly. Make a cpy f the cmpleted Applicatin, including all f the dcumentatin and attachments, fr yur recrds. The Applicatin and all accmpanying dcuments will becme the prperty f OASAS and will nt be returned. This will be very imprtant shuld yur applicatin expire befre yu fulfill all the requirements as yu wuld then be required t submit a new applicatin and all assciated dcumentatin. Submit the cmpleted riginal Applicatin and required dcumentatin. Attach the nn-refundable $100 Applicatin Prcessing Fee t the cmpleted Part A f this Applicatin. The Applicatin Prcessing Fee must be payable t NYS OASAS and in the frm f a certified check r mney rder. Applicatins received withut payment will nt be reviewed. Please mail yur Applicatin t: NYS OASAS Attn: Credentialing Unit 1450 Western Avenue Albany, New Yrk 12203-3526 Persnal checks r cash will nt be accepted, will be returned, and will delay prcessing f yur applicatin. An applicatin is active fr a perid f five years frm the date f pstmark. If yu d nt cmplete the CASAC prcess by the expiratin date f yur CASAC Trainee Extensin, yu will need t submit a new applicatin and a $100 Applicatin Prcessing Fee. It is suggested that yu cntact the Credentialing Unit prir t submitting a new applicatin as there may be paperwrk that yu d nt have t re-submit. PDS-11 [September 2014] NYS OASAS Page 3 f 23
PART A APPLICATION SUMMARY CHECKLIST Please remember t: Review the Cann f Ethical Principles, Miscnduct, and Other Prhibited Acts (pages 7-8). Cmplete Part A - Applicatin Summary Frm. Enter yur full, 9-digit Scial Security Number n Part A. Attach t Part A the $100 Applicatin Prcessing Fee (in the frm f a certified check r mney rder, payable t NYS OASAS ). Failure t submit prper payment will delay prcessing f yur applicatin. Persnal checks cannt be accepted, will be returned and will delay prcessing f yur applicatin. Attach a cpy f yur highest level f cmpleted educatin (diplma r transcript). Sign and date n the reverse side f the Part A frm (must be within ne year). In rder t maintain the accuracy f the Credentialing database, please reprt all changes in yur pstal address, e-mail address, telephne number and/r yur name within ten business days, in writing, t: NYS OASAS ATTN: Credentialing Unit 1450 Western Avenue Albany NY 12203 Alternatively, yu may request a change f address by e- mailing the Credentialing Unit at: credentialing@asas.ny.gv. PDS-11 [September 2014] NYS OASAS Page 4 f 23
PART A APPLICATION SUMMARY FORM Imprtant Nte: Dcumentatin submitted withut a fully cmpleted Part A will nt be prcessed, will be returned, and will delay the review f yur applicatin. PERSONAL INFORMATION -- PLEASE PRINT CLEARLY LAST NAME: FIRST NAME: MIDDLE INITIAL: IF YOU HAVE BEEN KNOWN BY ANY OTHER NAME(S), PLEASE PROVIDE: SOCIAL SECURITY NUMBER: - - DATE OF BIRTH: Full 9-digit Number is Required Mnth Day Year MAILING ADDRESS: Street Address Apt. # City/Twn/Village State Zip Cde Cunty f Residence HOME TELEPHONE NUMBER: ( ) CELL PHONE NUMBER: ( ) E-MAIL ADDRESS: GENDER: Female Male Please nte that yu may be cntacted via this e-mail regarding yur Applicatin. DEMOGRAPHIC INFORMATION -- OPTIONAL CREDENTIALING OPTION Ethnicity: Military Service: Optin 1 CASAC Trainee White (Nn Hispanic) Yes (Exam Eligible) Black (Nn Hispanic) Asian/Pacific American Native American Hispanic Other: N If applicable, I wuld identify myself as a persn: in recvery frm addictin(s). recvering frm the effects f addictin(s) in my family. Optin 2 CASAC Trainee (Nn-Exam Eligible) Optin 3 CASAC (Exam Eligible) Please see page 2 fr instructins. EDUCATIONAL INFORMATION -- ATTACH PROOF OF HIGHEST LEVEL COMPLETED GED High Schl Diplma Assciates Degree Bachelrs Degree Masters Degree Dctral Degree PROFESSIONAL INFORMATION -- ATTACH PROOF Licensed Clinical Scial Wrker Licensed Master Scial Wrker Certified by the Natinal Bard fr Certified Cunselrs Licensed Mental Health Cunselr Licensed Marriage and Family Therapist Registered Occupatinal Therapist Certified Rehabilitatin Cunselr Physician Physician s Assistant Registered Prfessinal Nurse Licensed Nurse Practitiner Licensed Psychlgist Licensed Psychanalyst Therapeutic Recreatin Specialist Licensed Creative Arts Therapist THE REVERSE SIDE MUST BE COMPLETED IN ITS ENTIRETY PDS-11 [September 2014] NYS OASAS Page 5 f 23
PART A APPLICATION SUMMARY FORM (cntinued) EMPLOYMENT INFORMATION PLEASE PRINT CLEARLY ARE YOU CURRENTLY EMPLOYED? Yes -- Please cmplete the fllwing sectin. N -- G t the Affirmatins sectin. CURRENT JOB TITLE: WORK TELEPHONE NO.: ( ) - Ext. EMPLOYER: DATE STARTED: OASAS CERTIFICATE NUMBER: (if applicable) WORK UNIT/FACILITY NAME: WORK ADDRESS: Street City/Twn/Village State Zip Cde AFFIRMATIONS AND CERTIFICATIONS (Please Print Clearly) HAS ANY DISCIPLINARY ACTION EVER BEEN TAKEN AGAINST YOU AS THE HOLDER OF ANY STATE LICENSE OR CERTIFICATION? N Yes - If Yes, cmplete the fllwing infrmatin and attach supprting dcumentatin. Date f Disciplinary Actin License r Certificatin Type f Actin Taken I, the undersigned applicant, have received as part f this Applicatin, and have read, understand, and agree t abide by the Part 853 Regulatins* gverning the Credentialing f Addictins Prfessinals, which includes the Cann f Ethical Principles, Miscnduct, and Other Prhibited Acts (pages 7-8 f this applicatin). I attest that the infrmatin cntained in this Applicatin, including any attachments, is true and crrect t the best f my knwledge. I understand that if the infrmatin submitted cntains a false statement, my Applicatin t becme a CASAC r CASAC Trainee may be denied. If the Applicatin is apprved and later determined t cntain materials that were false r misleading, OASAS has the authrity t duly annul, suspend, limit, r revke the credential issued.** APPLICANT SIGNATURE DATE *** * Any CASAC, CASAC Trainee, r CASAC Applicant wh engages in any acts prhibited by the Part 853 Regulatins gverning the Credentialing f Addictins Prfessinals shall be subject t ne r mre f the fllwing penalties r as therwise authrized by law: Administrative Reprimand, Suspensin, Denial f Renewal/Reinstatement, Revcatin, Fines, and Annulment. ** OFFERING A FALSE INSTRUMENT FOR FILING IN THE FIRST DEGREE IS A CLASS E FELONY. A persn is guilty f ffering a false instrument fr filing in the first degree when, knwing that a written instrument cntains a false statement r false infrmatin and, with intent t defraud the State r any plitical subdivisin theref, he/she ffers r presents it t a public ffice r public servant with the knwledge r belief that it will be filed with, registered r recrded in r therwise becme part f the recrds f such public ffice f public servant. *** Part A must be dated within ne year prir t submissin. Applicatins which are nt signed and dated will be returned and will delay prcessing f yur Applicatin. Persnal infrmatin prvided t OASAS is prtected under the New Yrk State Public Officer s Law, Persnal Privacy Prtectin Law, Article 6A, and may nly be disclsed with written cnsent, a curt-rdered subpena r subject t ther prvisins f such law. PDS-11 [September 2014] NYS OASAS Page 6 f 23
CANON OF ETHICAL PRINCIPLES Imprtant Nte: By signing the attestatin n Part A f this Applicatin, yu are certifying that yu received and have read, understand, and agree t abide by the fllwing Cann f Ethical Principles and the Miscnduct and Other Prhibited Acts sectins referenced n the fllwing page. The CASAC and CASAC Trainee: (1) Must practice bjectivity and integrity; maintain the highest standards in the services ffered; respect the values, attitudes and pinins f thers; and prvide services nly in an apprpriate prfessinal relatinship. (2) Must nt discriminate in wrk-related activities based n race, religin, age, gender, disabilities, ethnicity, natinal rigins, sexual rientatin, ecnmic cnditin r any ther basis prscribed by law. (3) Must respect the integrity and prtect the welfare f the persn r grup with whm the cunselr is wrking. (4) Must embrace, as a primary bligatin, the duty f prtecting the privacy f patients and must nt disclse cnfidential infrmatin r recrds under his/her cntrl in strict accrdance with federal, state and lcal laws. (5) Must nt engage in relatinships with patients, frmer patients r significant thers in which there is a risk f explitatin r ptential harm t the patient. (6) Must nt engage in any sexual activity with current r frmer patients r their significant thers. (7) Must nt knwingly engage in behavir that is harassing r demeaning, including, but nt limited t, sexual harassment. (8) Must nt explit patients r thers ver whm they have a psitin f authrity. (9) Must treat clleagues and ther prfessinals with respect, curtesy, and fairness and cperate in rder t serve the best interests f their patients. (10) Must ntify apprpriate authrities, including emplyers and OASAS, when they have direct knwledge f a clleague's impairment r miscnduct which interferes with treatment effectiveness and ptentially places patients and thers at risk. (11) Is expected t recgnize the effects f their wn impairment n prfessinal perfrmance and must nt prvide services that create cnflict f interest r impair wrk perfrmance and clinical judgment. (12) Must cperate with investigatins, prceedings, and requirements f OASAS r ther authrities which have jurisdictin ver thse charged with a vilatin. (13) Must nt participate in the filing f ethics cmplaints that are frivlus r have a purpse ther than t prtect the public. (14) Must assure that financial practices are in accrd with prfessinal standards that safeguard the best interests f the patient, the cunselr and the prfessin. (15) Must take reasnable steps t ensure that dcumentatin in recrds is accurate, sufficient and timely thereby ensuring apprpriateness and cntinuity f services prvided t patients. (16) Must uphld the legal and accepted mral cdes which pertain t prfessinal cnduct. (17) Must recgnize the need fr nging educatin t maintain current cmpetence, and t imprve expertise and skills. (18) Must acknwledge the limits f present knwledge in public statements cncerning alchlism and substance abuse. The Credentialed Alchlism and Substance Abuse Cunselr must reprt fairly and accurately the apprpriate infrmatin, and must acknwledge and dcument materials and techniques used. (19) Must assign credit t all wh have cntributed t the published material and fr the wrk upn which publicatin is based. (20) Must strive t infrm the public f the effects f alchlism and substance abuse. The Credentialed Alchlism and Substance Abuse Cunselr must adpt a persnal and prfessinal stance which prmtes the well-being f the recvery cmmunity. PDS-11 [September 2014] NYS OASAS Page 7 f 23
MISCONDUCT The fllwing shall cnstitute miscnduct by a CASAC and CASAC Trainee: (1) btaining the credential fraudulently; (2) practicing r prviding services fraudulently, with grss incmpetence, with grss negligence n a particular ccasin r negligence r incmpetence n mre than ne ccasin, r therwise acting cntrary t the interests f a patient r service recipient; (3) practicing r prviding services while under the influence f alchl and/r ther substances; (4) vilating any term r cnditin r limitatin impsed n the certified/credentialed prfessinal by the Office; (5) refusing t prvide services t a persn, individual, rganizatin r cmmunity because f race, creed, clr, gender, age, disability, natinal rigin, sexual rientatin, r sciecnmic status; (6) being cnvicted f r cmmitting an act cnstituting a crime under New Yrk State law, Federal law, r the law f anther jurisdictin which, if cmmitted within this State, wuld cnstitute a crime under New Yrk State law, and nt prmptly reprting such cnvictin t the Office; (7) prmting the inapprpriate sale f services, gds, prperty r drugs in such manner as t explit the patient r service recipient fr the financial gain f the certified/credentialed prfessinal r f a third party; (8) directly r indirectly ffering, giving, sliciting r receiving, r agreeing t receive, any fee, r ther cnsideratin t r frm a third party fr the referral f a patient r service recipient in cnnectin with the perfrmance f chemical dependence cunseling services r alchl and substance use, abuse and dependence preventin services; and/r prblem gambling services; (9) entering int an explitative, sexual r ther relatinship with patients/frmer patients/service recipients r their significant thers that is utside the bundaries f prfessinal cnduct; and (10) engaging in any cnduct which wuld cnstitute a reprtable incident as such terms are defined in Part 836* f this Title. * 14 NYCRR Part 836 [Incident Reprting in OASAS Certified, Licensed, Funded r Operated Services] OTHER PROHIBITED ACTS (a) (b) Unlawful use f the title CASAC r CASAC Trainee. N persn shall use the title CASAC r CASAC Trainee unless authrized pursuant t this Part. Private practice prhibited. N persn shall use the title CASAC r CASAC Trainee t engage in private practice unless therwise authrized by law. If yu suspect an individual has vilated the CASAC Cann f Ethical Principles, Miscnduct, r Other Prhibited Acts, please call the OASAS Credentialing Unit at 1-800-482-9564 (ptin 5). PDS-11 [September 2014] NYS OASAS Page 8 f 23
PART B EVALUATION OF ETHICAL CONDUCT CHECKLIST NOTE: Applicants must submit a cmpleted Part B Evaluatin f Ethical Cnduct in rder t be accepted and reviewed. Please remember t: Make enugh cpies f the Evaluatin f Ethical Cnduct frm fr all three f yur evaluatrs. Cmplete, sign, and date the Applicant Cnsent t Release Infrmatin sectin f each Evaluatin f Ethical Cnduct frm and prvide the frm t each evaluatr. Only submit evaluatins frm each evaluatr wh have knwn yu fr a minimum f 6 mnths. Evaluatrs must be a current r mst recent clinical supervisr, CASAC, and/r Qualified Health Prfessinal. Request that each evaluatr: (1) cmplete the entire evaluatin; (2) attach a cpy f their license r credential; (3) discuss the evaluatin with yu; and (4) return the cmpleted frm t yu, with any ther dcumentatin required. Include three cmpleted Evaluatins f Ethical Cnduct and any ther accmpanying dcumentatin. Part B des nt need t be submitted at this time if yu are trying t btain a CASAC Trainee. Include a cpy f a current credential claimed by each evaluatr. Check t make sure that the Evaluatin f Ethical Cnduct frms are dated within ne year prir t submissin. PDS-11 [September 2014] NYS OASAS Page 9 f 23
PART B EVALUATION OF ETHICAL CONDUCT Part B Requirements Yu must have three individuals cmplete an Evaluatin f Ethical Cnduct fr yu. Evaluatins may nt be cmpleted by family members, subrdinates, r instructrs and/r prfessrs. Evaluatins must be submitted n the Part B Evaluatin f Ethical Cnduct frms (pages 11 t 12) f this Applicatin Packet. All evaluatrs must have direct knwledge f yur alchlism and substance abuse-related wrk experience bserved fr a minimum f six mnths and must meet the fllwing qualificatins: One evaluatr must be yur current clinical supervisr. If yu were previusly emplyed in the substance abuse field but are currently emplyed in a nn-oasas setting, an evaluatin by yur frmer clinical supervisr must be submitted. One evaluatr must be a current New Yrk State CASAC r hld a current reciprcal-level credential issued by anther member bard f the ICRC. In additin t the CASAC evaluatr, ne evaluatr must be a Qualified Health Prfessinal (QHP). A QHP means an individual wh has at least ne year experience in the treatment f alchlism and/r substance abuse and wh has cmpleted a frmal training prgram in the treatment f alchlism and/r substance abuse, in accrdance with Part 853 Credentialing f Addictin Prfessinals regulatins, and is a/an: CASAC; Licensed Master r Licensed Clinical Scial Wrker; Nurse Practitiner; Occupatinal Therapist; Physician; Physician s Assistant; Registered Prfessinal Nurse; Psychlgist; Rehabilitatin Cunselr; Therapeutic Recreatin Specialist; Licensed Mental Health Cunselr; Marriage and Family Therapist; Licensed Creative Arts Therapist; Licensed Psychanalyst licensed; r Cunselr certified by the Natinal Bard fr Certified Cunselrs. Please nte that OASAS may nt intervene in wrkplace disputes shuld a supervisr refuse t sign an evaluatin frm. PDS-11 [September 2014] NYS OASAS Page 10 f 23
PART B EVALUATION OF ETHICAL CONDUCT FORM APPLICANT TO COMPLETE THIS SECTION - CONSENT TO RELEASE INFORMATION Please Print Clearly LAST NAME: FIRST NAME: SSN #: XXX-XX- By my signature belw, I am authrizing the prvider/persn identified belw t prvide infrmatin and dcumentatin t NYS OASAS. Applicant Signature Date Applicant Reminder: Make cpies f the Evaluatin f Ethical Cnduct frm t prvide t all three evaluatrs. EVALUATOR TO COMPLETE FROM THIS POINT FORWARD -- Please Print Clearly and Answer ALL Questins Infrmatin and Instructins t Evaluatr: The abve-named individual is applying t OASAS t becme a CASAC. As part f the applicatin prcess, the applicant has selected yu as ne f three persns wh is cnsidered cmpetent t judge his/her ethical cnduct. D nt cmplete the Evaluatin f Ethical Cnduct unless the abve release is signed and dated. Please return this cmpleted frm t the applicant with any ther dcumentatin required. If yu have any questins related t this frm, r t the evaluatin prcess, please cntact the OASAS Credentialing Unit at 1-800-482-9564 (ptin 2). Nte: Yes N Evaluatr has direct knwledge f the applicant s alchlism and substance abuse-related wrk experience bserved fr a minimum f six mnths. If yes, cntinue t cmplete the remainder f this frm. Evaluatr des nt have direct knwledge f the applicant s alchlism and substance abuse-related wrk experience bserved fr a minimum f six mnths D nt prceed any further and please return this frm t the applicant. EVALUATOR NAME: WORK SITE PHONE NUMBER: ( ) CURRENT PROVIDER/EMPLOYER: PHYSICAL WORK ADDRESS: CURRENT JOB TITLE: Street City/Twn/Village State Zip Cde PROFESSIONAL INFORMATION -- Check all credentials/ licenses that verify yur status as a QHP. As a QHP, yu must have had at least ne year f experience in the treatment f alchlism and/r substance abuse and have cmpleted a frmal training prgram in the treatment f alchlism and substance abuse in accrdance with the Part 853 Regulatin (Credentialing f Addictins Prfessinals). Attach a cpy f at least ne f the current credentials claimed. CASAC # Licensed Clinical Scial Wrker Licensed Master Scial Wrker Certified by the Natinal Bard fr Certified Cunselrs Licensed Mental Health Cunselr Licensed Marriage and Family Therapist Physician Physician s Assistant Registered Prfessinal Nurse Licensed Nurse Practitiner Licensed Psychlgist Other: Licensed Psychanalyst Therapeutic Recreatin Specialist Registered Occupatinal Therapist Certified Rehabilitatin Cunselr Licensed Creative Arts Therapist EVALUATOR KNOWLEDGE OF APPLICANT -- Check the bx that describes yur current relatinship t the applicant. Current Clinical Supervisr Frmer Clinical Supervisr C-Wrker Frmer C-Wrker Other: Perid cvered in prfessinal relatinship with applicant (six mnth minimum): (Mnth/Year) T (Mnth/Year) Evaluatr s Emplyer During Prfessinal Relatinship: Evaluatr s Jb Title During Prfessinal Relatinship: Applicant s Emplyer During Prfessinal Relatinship: Applicant s Jb Title During Prfessinal Relatinship: THE REVERSE SIDE MUST BE COMPLETED IN ITS ENTIRETY PDS-11 [September 2014] NYS OASAS Page 11 f 23
PART B EVALUATION OF ETHICAL CONDUCT The CASAC and CASAC Trainee: (1) Must practice bjectivity and integrity; maintain the highest standards in the services ffered; respect the values, attitudes and pinins f thers; and prvide services nly in an apprpriate prfessinal relatinship. (2) Must nt discriminate in wrk-related activities based n race, religin, age, gender, disabilities, ethnicity, natinal rigins, sexual rientatin, ecnmic cnditin r any ther basis prscribed by law. (3) Must respect the integrity and prtect the welfare f the persn r grup with whm the cunselr is wrking. (4) Must embrace, as a primary bligatin, the duty f prtecting the privacy f patients and must nt disclse cnfidential infrmatin r recrds under his/her cntrl in strict accrdance with federal, state and lcal laws. (5) Must nt engage in relatinships with patients, frmer patients r significant thers in which there is a risk f explitatin r ptential harm t the patient. (6) Must nt engage in any sexual activity with current r frmer patients r their significant thers. (7) Must nt knwingly engage in behavir that is harassing r demeaning, including, but nt limited t, sexual harassment. (8) Must nt explit patients r thers ver whm they have a psitin f authrity. (9) Must treat clleagues and ther prfessinals with respect, curtesy and fairness and cperate in rder t serve the best interests f their patients. (10) Must ntify apprpriate authrities, including emplyers and OASAS, when they have direct knwledge f a clleague's impairment r miscnduct which interferes with treatment effectiveness and ptentially places patients and thers at risk. (11) Is expected t recgnize the effects f their wn impairment n prfessinal perfrmance and must nt prvide services that create cnflict f interest r impair wrk perfrmance and clinical judgment. (12) Must cperate with investigatins, prceedings, and requirements f OASAS r ther authrities which have jurisdictin ver thse charged with a vilatin. (13) Must nt participate in the filing f ethics cmplaints that are frivlus r have a purpse ther than t prtect the public. (14) Must assure that financial practices are in accrd with prfessinal standards that safeguard the best interests f the patient, the cunselr and the prfessin. (15) Must take reasnable steps t ensure that dcumentatin in recrds is accurate, sufficient and timely thereby ensuring apprpriateness and cntinuity f services prvided t patients. (16) Must uphld the legal and accepted mral cdes which pertain t prfessinal cnduct. (17) Must recgnize the need fr nging educatin t maintain current cmpetence, and t imprve expertise and skills. (18) Must acknwledge the limits f present knwledge in public statements cncerning alchlism and substance abuse. The Credentialed Alchlism and Substance Abuse Cunselr must reprt fairly and accurately the apprpriate infrmatin, and must acknwledge and dcument materials and techniques used. (19) Must assign credit t all wh have cntributed t the published material and fr the wrk upn which publicatin is based. (20) Must strive t infrm the public f the effects f alchlism and substance abuse. The Credentialed Alchlism and Substance Abuse Cunselr must adpt a persnal and prfessinal stance which prmtes the well-being f the recvery cmmunity. EVALUATOR SUMMARY: Please check ne f the fllwing bxes and prvide cmments belw as apprpriate. I ENDORSE THIS APPLICANT. I am nt a relative r a subrdinate. I have n reservatins regarding the applicant s ethical cnduct. The applicant meets r exceeds ethical standards. T the best f my knwledge, the applicant has n current prblem with alchl, ther drugs r any ther addictins r cnditins which might interfere with his/her ability t perfrm as a CASAC. I have discussed this endrsement with the applicant. I DO NOT ENDORSE THIS APPLICANT. I have serius reservatins abut the applicant s ethical cnduct r ther cnditin which culd interfere with his/her ability t perfrm as a CASAC. I have discussed these reservatins with the applicant. I AM UNABLE TO EVALUATE THIS APPLICANT. COMMENTS : EVALUATOR ATTESTATION -- I attest that the infrmatin I have prvided is true and crrect t the best f my knwledge. I have directly bserved and prvided my best independent judgment f the applicant s wrk as an alchlism and substance abuse cunselr. I have nt been influenced by the pinins f any ther persn. I will nt discuss r reveal the cntent f this evaluatin with any persn ther than the applicant in that I cnsider it t be cnfidential and private. Evaluatr Signature Date * * Must be dated within ne year prir t submissin f the Part B frm. Frms nt dated within ne year prir t submissin cannt be cnsidered. PDS-11 [September 2014] NYS OASAS Page 12 f 23
PART C WORK EXPERIENCE VERIFICATION CHECKLIST NOTE: Applicants must submit a cmpleted Part C Wrk Experience Verificatin Recrd Frm t be accepted and reviewed. Please remember t: Cmplete Part C Wrk Experience Verificatin Recrd(s) and any ther dcumentatin required. Part C des nt need t be submitted at this time if yu are trying t btain a CASAC Trainee unless yu are using wrk experience twards the requirements (see ptin 2 n page 2). Include a cpy f at least ne current credential r license claimed by yur clinical supervisr. Include a cpy f the emplyer s perating certificate/license if applicable. Page 17 must include the signature f the: Authrized Representative Certificatin (fr paid wrk experience) r clinical supervisr (fr vlunteer/nn-paid wrk experience). Include ttal numbers f hurs wrked in clck hurs. Days/weeks wrked will nt be accepted. Include nly thse hurs wrked specific t the prvisin f substance abuse treatment services. Check wrk setting #3 fr a nn-certified setting, if applicable. PDS-11 [September 2014] NYS OASAS Page 13 f 23
PART C WORK EXPERIENCE Apprved Wrk Experience Wrk experience claimed must: include the prvisin f direct patient services r prvisin f dcumented supervisin f direct patient services; include practice specific t alchlism and substance abuse cunseling in the fllwing prfessinal tasks: diagnstic assessment, evaluatin, interventin, referral, and alchlism and/r substance abuse cunseling in bth individual and grup settings; include a minimum f mnthly, n-site and dcumented clinical supervisin by a QHP (as defined n page 10); be integrated with the alchlism and/r substance abuse services delivery system fr cnsultatin and referrals; include practice in alchlism and/r substance abuse cunseling t establish and maintain recvery and prevent relapse; include a minimum f 300 hurs f Supervised Practical Training. Each f the fllwing 12 Cre Functins must have been perfrmed fr a minimum f 10 hurs, under the supervisin f a QHP: Screening Intake Cunseling Case Management Orientatin Assessment, Evaluatin and Interventin Crisis Interventin Reprting and Recrd Keeping Referral Treatment Planning Patient Educatin Cnsultatin with Other Prfessinals T satisfy the 6,000 hur wrk experience requirement, a minimum f 2,000 hurs must be gained during the five years prir t the submissin f a Wrk Experience Verificatin Recrd. OASAS strngly encurages that the majrity f yur wrk experience be devted t the practice f alchlism and/r substance abuse cunseling. Yu must dcument a minimum f 6,000 hurs (apprximately three years full-time) f supervised experience in an apprved wrk setting as a supervisr f direct patient services. An apprved wrk setting means: (1) It is perated by OASAS (i.e., Addictin Treatment Centers) and/r it hlds a valid OASAS perating certificate t prvide treatment services. (2) It is a prgram that includes alchlism and/r substance abuse treatment cnsistent with OASAS standards and is licensed and/r perated by anther recgnized State r Federal authrity t include the Indian Health Service and Veterans Administratin (e.g., OMH). (3) It is a nn-certified setting which invlves the legal prvisin f treatment services and which affrds the pprtunity t establish prficiency in ne r mre f the prfessinal cmpetencies assciated with a credential administered by OASAS and n-site supervisin by a QHP meeting the supervisry standards established by OASAS. Only 50 percent f the required wrk experience may be btained in this wrk setting. Wrk experience may nt include any experience gained as part f, r required under, participatin as a patient in a frmal prblem gambling prgram r a frmal alchlism and/r substance abuse treatment/aftercare prgram and/r plan. PDS-11 [September 2014] NYS OASAS Page 14 f 23
PART C WORK EXPERIENCE (cntinued) Academic Degrees Substitutin f an Assciate s Degree, Bachelr s Degree r Master s (r higher) Degree in an apprved Human Services Field (see belw list) fr wrk experience must be supprted by either an academic transcript r a cpy f yur diplma frm an accredited cllege r institutin which clearly states the apprved Human Services Field. The fllwing academic degree substitutins may be claimed tward satisfying the 6,000 hur wrk experience requirement. Only ne academic degree substitutin may be applied: Assciate s Degree -- May be substituted fr a maximum f 1,000 hurs f wrk experience. Bachelr s Degree -- May be substituted fr a maximum f 2,000 hurs f wrk experience. Master s (r higher) Degree -- May be substituted fr 4,000 hurs f wrk experience. Examples f apprved Human Services Fields include: Anthrplgy Art/Dance Therapy Audilgy Child Develpment/Family Relatins Cmmunity Mental Health Chemical Dependence Administratin Cunseling/Guidance Criminal Justice Divinity/Religin/Thelgy Drama Therapy Educatin Gerntlgy Health Administratin Health Educatin Speech Pathlgy Human Services Music Therapy Nursing/Medicine Nutritin Occupatinal Therapy Pastral Cunseling Physical Therapy Psychlgy Recreatinal Therapy Rehabilitatin Cunseling Scial Wrk Scilgy Special Educatin Vcatinal Cunseling Nte: Other degrees may be cnsidered if at least 50 percent f the cursewrk is in the Human Services Field. It is very imprtant t nte the fllwing: Certificates f Advanced Study and Teaching Certificates are nt cnsidered r cmparable t attainment f a degree. A frmal internship r frmal field placement may be claimed as wrk experience r educatin and training, but nt bth. Yu shuld calculate the need t claim a frmal internship r frmal field placement as either wrk experience r educatin and training. Did yu knw that all CASACs, CASAC Trainees, and Applicants are Mandated Reprters? It is a Mandated Reprter s legal duty under the New Yrk State Prtectin f Peple with Special Needs Act (the Act) t reprt Abuse, Neglect and Significant Incidents invlving vulnerable persns t the Vulnerable Persns Central Register (VPCR). The Justice Center perates a centralized, statewide tll-free htline and incident reprting system, knwn as the Vulnerable Persns Central Register (VPCR), which receives and tracks allegatins f abuse and neglect 24 hurs a day, 7-days a week. The Justice Center Htline number is 1-855-373-2122. PDS-11 [September 2014] NYS OASAS Page 15 f 23
PART C WORK EXPERIENCE VERIFICATION RECORD FORM THIS SECTION TO BE COMPLETED BY THE APPLICANT LAST NAME: FIRST NAME: SSN #: XXX-XX- Cnsent t Release Infrmatin -- By my signature belw, I am authrizing the prvider/persn identified belw t prvide infrmatin and dcumentatin t OASAS. I attest that the wrk experience hurs claimed were NOT gained during the curse f, r as part f, my participatin as a patient in a frmal alchlism and/r substance abuse treatment/aftercare prgram and/r plan. Applicant Signature Date THIS SECTION TO BE COMPLETED BY THE APPLICANT S SUPERVISOR Must be a Qualified Health Prfessinal (QHP) This frm reflects yur knwledge f the applicant s wrk experience and/r supervised practical training while emplyed at the wrk setting indicated. Be sure that the applicant has signed and dated the abve Applicant Cnsent t Release Infrmatin allwing yu t make available t OASAS any and all infrmatin regarding his/her wrk experience needed t meet the CASAC eligibility requirements. Please return this cmpleted frm t the applicant with any ther dcumentatin. Questins may be directed t the OASAS Credentialing Unit at 1-800-482-9564 (ptin 2). PROVIDER/EMPLOYER NAME: UNIT WHERE APPLICANT WORKED: OASAS OPERATING CERTIFICATE #: WORK SITE TELEPHONE NUMBER: ( ) WORK ADDRESS (Must match OASAS Operating Certificate as listed abve): TYPE OF WORK SETTING Check Only One: Street City/Twn/Village State Zip Cde (1) It is perated by OASAS (i.e., Addictin Treatment Centers) and/r it hlds a valid OASAS perating certificate t prvide treatment services r a similar license r apprval frm anther state. (2) It is a prgram that includes alchlism and/r substance abuse treatment cnsistent with OASAS standards and is licensed and/r perated by anther recgnized State r Federal gvernment authrity t include the Indian Health Service and Veterans Administratin. (3) It is a nn-certified setting which invlves: (1) the legal prvisin f treatment services; (2) the pprtunity t establish prficiency in ne r mre f the prfessinal cmpetencies assciated with a credential administered by OASAS; and (3) n-site supervisin by a QHP meeting the supervisry standards established by OASAS. Only 50 percent f the required wrk experience may be btained in this wrk setting. * NOTE: If yu ve chsen wrk setting #3, yu are nt authrized t prvide Individual/Grup Cunseling (chemical dependence) and/r Treatment Planning. Prvisin f such services may require OASAS certificatin. SUPERVISED PRACTICAL TRAINING/SUPERVISOR CERTIFICATION Supervised Practical Training must be specific t alchlism and substance abuse cunseling fr Wrk Settings #2 and #3. Must include weekly, nsite, and dcumented clinical supervisin by a QHP. Each f the 12 Cre Functins must have been perfrmed fr a minimum f 10 hurs and a ttal f 300 hurs under the supervisin f a QHP. These minimum hurs may be btained frm ne r mre supervisr(s)/ prvider(s)/ emplyer(s). In each f the fllwing 12 Cre Functins (areas f prfessinal expertise), the supervisr prvided supervised practical training t the applicant as part f his/her wrk experience. The supervisr has reviewed the recrds and certifies that the infrmatin prvided n the supervised practical training f the abve-named applicant is true t the best f their knwledge and belief. * In accrdance with Mental Hygiene Law 32.05, it is imprtant t nte that, if yu are prviding Individual/Grup Cunseling (chemical dependence) and/r Treatment Planning, yur prgram may require certificatin by OASAS. SUPERVISED PRACTICALTRAINING: Screening Intake Referral Orientatin Treatment Planning * Case Management Crisis Interventin Cunseling * Patient Educatin Assessment, Evaluatin and Interventin Reprting and Recrd Keeping Cnsultatin with Other Prfessinals TOTAL # HOURS: # HOURS: THE REVERSE SIDE MUST BE COMPLETED IN ITS ENTIRETY PDS-11 [September 2014] NYS OASAS Page 16 f 23
PART C WORK EXPERIENCE VERIFICATION RECORD FORM (cntinued) APPLICANT JOB RESPONSIBILITIES: During the dates f emplyment indicated belw, the applicant was respnsible fr chemical dependence related practice in the fllwing areas (check all that apply): Diagnstic Assessment Evaluatin Interventin Referral Alchlism and/r Substance Abuse Cunseling (Individual) * Alchlism and/r Substance Abuse Cunseling (Grup) * * In accrdance with Mental Hygiene Law 32.05, it is imprtant t nte that, if yu are prviding Individual/Grup Cunseling (chemical dependence), yur prgram may require certificatin by OASAS. QUALIFIED HEALTH PROFESSIONAL CERTIFICATION: Check all current credentials r licenses that verify yur status as a QHP. Attach a cpy f at least ne f the current credentials claimed. CASAC # Licensed Clinical Scial Wrker Licensed Master Scial Wrker Certified by the Natinal Bard fr Certified Cunselrs Licensed Mental Health Cunselr Licensed Marriage and Family Therapist Physician Physician s Assistant Registered Prfessinal Nurse Licensed Nurse Practitiner Licensed Psychlgist Other: Licensed Psychanalyst Therapeutic Recreatin Specialist Registered Occupatinal Therapist Certified Rehabilitatin Cunselr Licensed Creative Arts Therapist I attest that, as a QHP, I have had at least ne year f experience in the treatment f alchlism and/r substance abuse, I have cmpleted a frmal training prgram in the treatment f alchlism and/r substance abuse, and that the supervised training hurs claimed abve were nt gained during the curse f, r as part f, the applicant s participatin as a patient in a frmal alchlism and/r substance abuse treatment/aftercare prgram and/r plan. Name f Applicant s Supervisr (Please Print): Jb Title: ( ) Signature f Applicant s Supervisr Date Wrk Site Telephne Number WORK EXPERIENCE (Includes Supervised Practical Training) Is this a paid psitin? Yes -- A Human Resurces r Payrll Department representative must cmplete the fllwing sectin. N -- Yur current clinical supervisr as identified abve must cmplete the fllwing sectin. Applicant s Jb Title: Dates f Emplyment: t (mnth/day/year) (mnth/day/year) Ttal # Clck Hurs Actually Wrked (excluding hlidays, vacatin, sick leave, etc.): AUTHORIZED REPRESENTATIVE CERTIFICATION I have reviewed emplyment recrds and certify that the infrmatin prvided n the wrk experience hurs f the abve-named applicant is true t the best f my knwledge and belief. I attest that the wrk experience hurs claimed were nt gained during the curse f, r as part f, the applicant s participatin as a patient in a frmal alchlism and/r substance abuse treatment/aftercare prgram and/r plan. Name f Authrized Representative (Please Print): Jb Title: ( ) Signature f Authrized Representative Date Wrk Site Telephne Number Wrk experience may nt include any experience gained as part f, r required under, participatin as a patient in a frmal prblem gambling prgram r a frmal alchlism and/r substance abuse treatment/aftercare prgram and/r plan. PDS-11 [September 2014] NYS OASAS Page 17 f 23
PART D EDUCATION AND TRAINING CHECKLIST Please remember t: Attach either a certificate f cmpletin and/r academic transcripts. Transcripts must include yur name, name f institutin, degree/majr field f cncentratin, titles f cursewrk, date f cmpletin, and grade. Include curse descriptins fr the applicable cursewrk submitted. Did yu check t be sure that yu have prf f ne f the ptins as utlined at the tp f page 19. PDS-11 [September 2014] NYS OASAS Page 18 f 23
PART D EDUCATION AND TRAINING Optin Overview Applicant must submit the full 350 hurs r individual sectin requirement, depending n the ptin belw, in rder t be accepted and reviewed. Optin 1 One (1) OASAS CASAC 350-Hur Standardized Certificate f Cmpletin which incrprates all fur sectins (i.e., Sectin 1 85 clck hurs; Sectin II 150 clck hurs; Sectin III 70 clck hurs; and Sectin IV 45 clck hurs). Optin 2 Fur (4) individual OASAS Standardized Certificates f Cmpletin fr a full sectin (i.e., Sectin 1 85 clck hurs; Sectin II 150 clck hurs; Sectin III 70 clck hurs; and Sectin IV 45 clck hurs). Optin 3 An academic transcript thrugh an accredited institutin which cntains sufficient curse wrk t cmplete a full sectin (i.e., Sectin 1 85 clck hurs; Sectin II 150 clck hurs; Sectin III 70 clck hurs; and Sectin IV 45 clck hurs). Please nte that a frmal internship r frmal field placement may be claimed as either: educatin and training (based n the academic credit assciated with cmpletin, nt the number f hurs served in the field); r wrk experience. Yu need t claim a frmal internship r frmal field placement as either wrk experience r educatin and training (yu may nt claim as bth). Minimum Requirements - Summary Sectin I Knwledge f Alchlism and Substance Abuse (85 clck hurs) Must include a minimum f 4 hurs f training related t tbacc use and nictine dependence. Sectin II Alchlism and Substance Abuse Cunseling (150 clck hurs) Must include 15 hurs specific t Cultural Cmpetence. Sectin III Assessment; Clinical Evaluatin; Treatment Planning; Case Management; and Patient, Family and Cmmunity Educatin (70 clck hurs). Sectin IV Prfessinal and Ethical Respnsibilities (45 clck hurs) Must include 15 hurs specific t Ethics fr Addictin Prfessinals and a minimum f 2 hurs in Child Abuse and Maltreatment: Mandated Reprter NYS Educatin Department apprved training. Nte: Mandated reprter training can be btained free f charge at: www.nysmandatedreprter.rg. Educatin and Training Sectins Sectin I Knwledge f Alchlism and Substance Abuse (85 clck hurs) Must include a minimum f 4 hurs f training related t tbacc use and nictine dependence. Sectin I must include the fllwing curse cntent and assciated clck hurs: Basic Knwledge: Physical and Pharmaclgical Effects. Cntent must cver a minimum f 30 clck hurs. A minimum f 4 hurs f the 30 hurs must be related t tbacc use; nictine dependence; interventins; treatment and recvery and nictine replacement therapy (NRT). Curse wrk that prvides knwledge f: Alchl, Tbacc and Other Drugs (ATOD) use and abuse; hw the brain and ther bdy parts react t ATOD ingestin; ATOD pharmaclgy and interactin f ATOD with ther medicatins; the nature f addictin; the natural histry f alchlism and ther drug dependence; genetic factrs that may cntribute t dependence; and the Bi-Psych-Scial mdel f addictin; and particular substances f abuse (e.g., alchl, amphetamine and related substances, caffeine, cannabis, ccaine, hallucingens, inhalants, nictine, piids, phencyclidine and related substances, sedatives, hypntics, anxilytics, etc.). PDS-11 [September 2014] NYS OASAS Page 19 f 23
PART D EDUCATION AND TRAINING (cntinued) Overview f the Addictins Field. Cntent must cver a minimum f 28 clck hurs. Curse wrk that prvides knwledge f: the histry f alchl and drugs; terms and cncepts related t thery, research and practice and faith based treatment appraches; basic cncepts f scial, plitical, ecnmic and cultural systems and their impact n drug-taking activity; risk and prtectin factrs that characterize individuals and grups and their living envirnments; the cntinuum f addictin services, preventin, treatment, recvery and relevant levels f interventin and care; and the cntinuum f drug use t include initiatin; intxicatin; harmful use; abuse; dependence; withdrawal; relapse and recvery. Diversity f Interventin and Treatment Appraches. Cntent must cver a minimum f 12 clck hurs. Curse wrk that prvides knwledge f: specific therapy mdels; medicatin supprted recvery (medicatin assisted treatment), including but nt limited t methadne; buprenrphine; alchl dependence medicatins and psychiatric medicatins; nn-traditinal treatment methds; and the thery and practice f recgnized (i.e., having sme basis in literature, research, cmmn r licensed/regulated practice) interventin and treatment appraches; and OASAS licensed and/r funded mdalities and therapy mdels that address ATOD-related prblems and diagnses. Examples include Chemical Dependence Services: Part 816 - Chemical Dependence Withdrawal and Stabilizatin Services Part 817 - Chemical Dependence Residential Rehabilitatin Services fr Yuth Part 818 - Chemical Dependence Inpatient Rehabilitatin Services Part 819 - Chemical Dependence Residential Services Part 822 - Chemical Dependence Outpatient and Opiid Treatment Prgrams Part 823 - Outpatient Chemical Dependency Services fr Yuth Part 824 - Specialized Services Intrductin t Diagnstic Criteria. Cntent must cver a minimum f 6 clck hurs. Curse wrk that prvides knwledge f varius assessment instruments and diagnstic tls fr alchlism and substance abuse treatment, including but nt limited t the current Diagnstic and Statistical Manual (DSM), Internatinal Classificatin f Diseases (ICD) standards and the Addictin Severity Index (ASI), as well as level f care determinatin tls such as the OASAS LOCADTR and A.S.A.M. Patient Placement Criteria. Knwledge f 12 Step and Mutual Aid Grups. Cntent must cver a minimum f 6 clck hurs. Curse wrk that prvides knwledge f the histry, thery/philsphy, principles and practices f the 12 Steps and ther types f mutual aid grups. Txiclgy Testing/Screening. Cntent must cver a minimum f 3 clck hurs. Curse wrk that prvides knwledge f basic cncepts f txiclgy screening ptins, limitatins and legal implicatins as well as reprting language and the meaning f txiclgy reprts. Sectin II Alchlism and Substance Abuse Cunseling (150 clck hurs) Must include 15 hurs specific t Cultural Cmpetence. Sectin II must include the fllwing curse cntent and assciated clck hurs: Individual Cunseling. Cntent must cver a minimum f 45 clck hurs including 6 hurs f vcatinal-related skills and 6 hurs f relapse preventin skills. Curse wrk that prvides knwledge f: the essentials f alchlism and substance abuse cunseling with individuals, including the thery and practice f clinical management f the recvery f individuals, and the applicatin f diagnstic criteria; cunselr cmmunicatin skills; skills and techniques that fcus n the barriers t recvery including vcatinal habilitatin and ther multiple rehabilitatin needs; PDS-11 [September 2014] NYS OASAS Page 20 f 23
PART D EDUCATION AND TRAINING (cntinued) dealing with the bilgical, psychlgical, scial, emtinal and spiritual aspects f recvery and hw t integrate these t prevent the nset f active Alchl, Tbacc and Other Drugs (ATOD) use, relapse preventin planning, and lng term recvery; and cunseling individuals abut the use f addictin medicatins (including but nt limited t methadne; buprenrphine; alchl dependence medicatins; and psychiatric medicatins). Grup Cunseling. Cntent must cver a minimum f 30 clck hurs including 6 hurs f relapse preventin material. Curse wrk that prvides knwledge f: the essentials f alchlism and substance abuse cunseling with grups f individuals; the use f addictin medicatins (including but nt limited t methadne; buprenrphine; alchl dependence medicatins; and psychiatric medicatins); grup thery including stages f grup develpment and tasks f the cunselr at different stages f the prcess; grup dynamics, techniques and interventins used in grup settings and grup techniques designed fr r mdified fr, specific ppulatins; and supprt grups. Cunseling Special Ppulatins/Cultural Cmpetency. Cntent must cver a minimum f 30 clck hurs including 15 hurs specific t Cultural Cmpetency. Cursewrk that prvides knwledge f: the specific ATOD preventin/treatment needs f particular ppulatins and develpment f the skills necessary t effectively cunsel individuals in thse ppulatins. [ Special ppulatin is defined by race; minrity/prtected status; ethnicity; gender; religin; legal status; age; and/r ther status (t include cntent specific t veterans, trauma survivrs, criminal justice-invlved, sexual rientatin, dmestic vilence, c-existing psychiatric disrders, cmpulsive behavir disrders r ther disabilities.] an ability t understand, cmmunicate with, and effectively interact with peple acrss diverse cultures. [Cultural cmpetence cmprises fur cmpnents: (a) Awareness f ne's wn cultural wrldview, (b) Attitude twards cultural differences, (c) Knwledge f different cultural practices and wrldviews, and (d) Crss-cultural skills.] Effects n Family - Cunseling Families and Significant Others. Cntent must cver a minimum f 21 clck hurs including 6 hurs specific t relapse preventin with families/significant thers. Curse wrk that prvides knwledge f: the basic thery and skills needed by alchlism and substance abuse cunselrs t wrk effectively with individual family members, significant thers and whle families, including c-dependency; issues relating t children f chemically addicted persns; gengrams; the applicatin f systems thery t practice with families; and In additin, this sectin must address relapse preventin tpics (e.g. awareness f relapse prcess, maintaining cmmitment t recvery, utilizing available resurces) aimed t assist the families/significant thers f ATOD clients. Theries f Human Develpment and the Relatinship t Substance Abuse. Cntent must cver a minimum f 12 clck hurs. Curse wrk that prvides knwledge f varius theries n human grwth and develpment (i.e., physical, psychlgical, emtinal and spiritual develpment f human beings) with the emphasis n substance abuse. Health, Wellness and Cmmunicable Diseases. Cntent must cver a minimum f 12 clck hurs. Curse wrk that prvides knwledge f the medical issues cmmn t individuals with ATOD disrders, including HIV and AIDS, STD s, TB, hepatitis and ther cmmunicable diseases, as well as interventins which prmte health and wellness. Sectin III Assessment; Clinical Evaluatin; Treatment Planning; Case Management; and Patient, Family and Cmmunity Educatin (70 clck hurs) Sectin III must include the fllwing curse cntent and assciated clck hurs: Assessment and Evaluatin. Cntent must cver a minimum f 24 clck hurs. Curse wrk that prvides knwledge sufficient t determine the presence and extent f any Alchl, Tbacc and Other Drugs (ATOD)-related prblems and make a determinatin f any needed initial services t include: rapprt building; systematic data gathering frm client and cllateral surces cncerning all functinal areas; PDS-11 [September 2014] NYS OASAS Page 21 f 23
PART D EDUCATION AND TRAINING (cntinued) screening and assessment instruments; applicatin f accepted substance use disrder diagnstic criteria t make treatment recmmendatins; screening fr ther nn-substance specific issues which can impact n assessment and treatment planning (e.g., suicidality, indicatrs f pssible mental health disrder, medical cnditins, gambling prblems, etc.); determining treatment readiness; and sharing f assessment results. Treatment Planning, Client Recrd Keeping and Discharge Planning. Cntent must cver a minimum f 24 clck hurs. Curse wrk that prvides: knwledge f the cperative prcess by which cunselr and client devise an alchlism and substance abuse treatment plan; knwledge f cmpnents f the treatment plan including gal setting, measurable bjectives, time frames; activities, evaluatin, relapse preventin and discharge planning; knwledge f the rles and tasks f the interdisciplinary treatment team in carrying ut the treatment and discharge plan; knwledge f the cntent f clients' recrds and related dcumentatin and recrd-keeping methds and prcesses; knwledge f the essential cmpnents f client recrds; including release frms, assessments, treatment plans, prgress ntes and discharge summaries and plans t include skills t cmpse timely, clear, cmplete and cncise recrds that cmply with regulatins; dcumentatin f infrmatin in an bjective and legible manner; and skills t utilize new technlgies in the prductin f client recrds Case Management, Referral and Service Crdinatin. Cntent must cver a minimum f 12 clck hurs. Curse wrk that prvides: practical knwledge, and develps skills in case management, mnitring, nging assessment, and referral f the alchlism r substance abusing/dependent client t the apprpriate services in a suitable level f care; and knwledge n dcumentatin f service crdinatin activities thrughut the cntinuum f care and the ability t apply placement, cntinued stay and discharge criteria fr each mdality n the cntinuum f care. Patient, Family and Cmmunity Educatin and Preventin. Cntent must cver a minimum f 10 clck hurs. Curse wrk that prvides: Presentatin and training techniques that address hw t prvide relevant infrmatin abut ATOD abuse and related prblems t patients, families & cmmunities t encurage wellness and increase understanding f addictin; Presentatin and training techniques that address and supprt substance abuse preventin, treatment and the recvery prcess; Knwledge f the cnnectin f the theries and mdels f ATODG preventin t current best practices, including OASAS' Risk & Prtectin framewrk, SAMHSA's Strategic Preventin Framewrk, mdel prgrams and envirnmental strategies; and Knwledge f the imprtance f life skills t the preventin and treatment f substance use disrders. Sectin IV Prfessinal and Ethical Respnsibilities (45 clck hurs) Must include 15 hurs specific t Ethics fr Addictin prfessinals and a minimum f 2 hurs in Child Abuse and Maltreatment: Mandated Reprter NYS Educatin Department apprved training. Sectin IV must include the fllwing curse cntent and assciated clck hurs: Cunselr-Client Relatinships. Cntent must cver a minimum f 18 clck hurs. Curse wrk that prvides knwledge f the therapeutic alliance as a unique relatinship between cunselr and client, integrating basic cunseling skills, critical thinking, ethical standards and prfessinal respnsibilities t the client. Tpics include, but are nt limited t: clinical bundaries; transference and cuntertransference; cunselr self-disclsure; recvery issues; PDS-11 [September 2014] NYS OASAS Page 22 f 23
PART D EDUCATION AND TRAINING (cntinued) sexual harassment; respnse and respnsibility t seek and utilize clinical supervisin; and self-awareness regarding cultural bias and the need fr cultural cmpetency within the cunselr/client relatinship. Ethical Decisin Making and Cnduct. Cntent must cver a minimum f 9 clck hurs. Curse wrk that: prvides knwledge f the use f critical thinking and analysis in effective ethical decisin-making; examines the differences between virtue ethics and ethical decisin-making by frmal cdes f ethics; prvides knwledge f prfessinal and ethical respnsibilities f Addictins Cunselrs; includes frmal canns f ethical principles, must include but is nt limited t, the CASAC Cann f Ethical Principles, the American Psychlgical Assciatin Cde f Ethical Principles and Cde f Cnduct, the ethical cdes f the American Cunseling Assciatin and f the Natinal Assciatin f Scial Wrkers, the American Assciatin fr Marriage and Family Therapy and the Natinal Organizatin fr Human Service Educatin; and examines clinical supervisin as an ethical bligatin thrughut the career f a cunselr. Cnfidentiality/Legal Issues. Cntent must cver a minimum f 9 clck hurs. Curse wrk that prvides: knwledge f current federal (42CFR Part 2, Health Insurance Prtability and Accuntability Act [HIPAA] Sectins 160 & 164), and state laws gverning the apprpriate delivery f alchlism and substance abuse services; emphases n prgram specific plicies/prcedures invlving cnfidentiality, as well as legal issues that relate t alchlism and substance abuse clients; an understanding t seek clinical supervisin n cmplex issues relating t cnfidentiality and legal matters; and infrmatin which addresses cnfidentiality and legal issues assciated in wrk with clients impacted by HIV/AIDS. Child Abuse and Maltreatment: Mandated Reprter Training New Yrk State Educatin Department apprved training/curriculum (2 clck hurs). The NYS Office fr Children and Family Services (OCFS) Mandated Reprter Resurce Center ffers NYS Educatin Department apprved n-line training fr mandated reprters in New Yrk State s that every mandated reprter has the knwledge and skills t be able t effectively reprt child abuse r maltreatment/neglect t the NYS Child Abuse and Maltreatment Register. T access this curse: http://nysmandatedreprter.rg/trainingcurses.aspx. Cunselr Wellness. Cntent must cver a minimum f 7 clck hurs. Curse wrk that prvides: the definitin f cmpassin fatigue, burnut and ther jb-related stresses and hw t identify, prevent and recver frm its effects thrugh knwledge n: why cmpassin fatigue ccurs and wh is at risk; cnnectin between PTSD and cmpassin fatigue; recgnitin f symptms; and preventin and recvery strategies, including the rle f clinical supervisin; knwledge f the imprtance f self-care fr the Alchlism & Substance Abuse Cunselr, and the relatinship between a healthy bdy, a healthy mind and cunselr wellness, and techniques fr fstering that relatinship (Examples include but are nt limited t, nutritin awareness, relaxatin techniques, persnal grwth and clinical supervisin); knwledge f Cunselr Wellness prgrams, including hw t develp agency resurces t ffer cunselr assistance, especially alchlism & substance abuse interventin services and referrals (e.g. Emplyee Assistance Prgrams (EAP); and peer supprt; and knwledge f alchlism & substance abuse impairment and miscnduct and identificatin f such, as well as guidelines fr a cunselr s return t wrk as a direct care prvider fllwing a perid f impairment. PDS-11 [September 2014] NYS OASAS Page 23 f 23