SOP 107.17-att-1: Addiction Certification Preparation Program Application

# Addiction Certification Preparation Program Application

SOP 107.17
Attachment 1

03/31/22
Page 1 of 6

Date of Application: _______________

Applicant’s Name: ______________________________ Position: ______________________

Phone #: _________________________ Fax #: ____________________________

Email Address: __________________________________________________________________

Facility Name: ___________________________________________________________________

Supervisor’s Name: __________________________________ Phone #: ____________________

Location Address: ________________________________________________________________

Mailing Address: __________________________________________________________________

APPLICANT SECTION

Education:
(Please provide a copy of an unofficial transcript from each college/university.)

College/University Type of Degree Major
(Associate’s, Bachelor’s, Master’s, etc.)
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________

GDC Counseling Training:
(Examples: Initial Correctional Counselor Training, Motivational Interviewing, M4C, MRT, Matrix,
T4C, Anger Management, Problem Solving Skills in Action, etc.) Attach additional page if necessary.

Training Provider Date
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________
_____________________ ________________________ _______________________

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.

# Addiction Certification Preparation Program Application

SOP 107.17
Attachment 1

3/31/22
Page 2 of 6

Professional Conferences /Workshops:

Title of Workshop Provider Date
______________________ __________________________ _____________________
______________________ __________________________ _____________________
______________________ __________________________ _____________________
______________________ __________________________ _____________________

Professional Certifications/Licensures:

Type Awarded By Date Current

Yes/No
_______________________ __________________________ ____________ __________
_______________________ __________________________ ____________ __________
_______________________ __________________________ ____________ __________
_______________________ __________________________ ____________ __________

Have you ever been denied a certification or licensure? If so, what type of certification or licensure,
when, and why?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Are you currently working toward a certification or licensure? What? What are your remaining
requirements?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.

# Addiction Certification Preparation Program Application

SOP 107.17
Attachment 1

3/31/22
Page 3 of 6

Work History:

All:
Please list any employers, including your current employer, for whom you have worked where you
provided Direct Services to an identified substance abusing population. If you have worked at multiple
GDC facilities, please list each facility separately. Please indicate below if you received Clinical
Supervision while you were there.

Employer Date of Services # Hours per week of Direct S.A. Services
________________________ ________________ _________________________________
________________________ ________________ _________________________________
________________________ ________________ _________________________________
________________________ ________________ _________________________________

Hrs. of Clinical Supervision Supervisor’s Name
_________________________ ________________________________
_________________________ ________________________________
_________________________ ________________________________

Current:
Please list current job responsibilities that you perform directly to a substance abusing population
who has been identified by a formal assessment and/or an official override.

Responsibility # of Hrs Weekly
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________
____________________________________ ___________________________

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.

# Addiction Certification Preparation Program Application

SOP 107.17
Attachment 1

3/31/22
Page 4 of 6

Please initial next to each of the following statements indicating your commitment:

_____ I must obtain 4,000 hours (approximately two (2) years of working 40 hours per week) of
experience with an identified substance abusing population.

_____ I must attend the year-long training, in which sessions occur once a month, until I meet the
required 300 hours of training in all Twelve (12) Core Functions (Screening, Intake, Orientation,
Assessment, Treatment Planning, Counseling, Case Management, Crisis Intervention, Client
Education, Referral, Reports and Record Keeping, and Consultation). I also know other training
may be involved. I recognize that I might have to pay out-of-pocket for additional training.

_____ I must obtain 200 hours of Clinical Supervision with a minimum of ten (10) hours in each of the

12 Core Functions. A supervisor should have a good clinical background in substance abuse,
chemical dependencies, and co-occurring disorders. The preferred credential for a Clinical
Supervisor is the Alcohol and Drug Abuse Certification Board of Georgia’s (ADACBGA)
Certified Clinical Supervisor ( CCS ) and/or the IC&RC International Certified Clinical
Supervisor ( ICCS ). Other acceptable credentials for Clinical Supervisors, which will require
case-by-case approval by the ADACBGA ahead of the provision of Clinical Supervision, are:

- Licensed Professional Counselor ( LPC ) _who also holds_ the Certified Professional

Counselor Supervisor ( CPCS ) through LPCA of Georgia _and/_ _or_ the Approved
Clinical Supervisor ( ACS ) through the Center for Credentialing & Education
( CCE ) of the National Board for Certified Counselors ( NBCC ),

- Licensed Clinical Social Worker ( LCSW ) _who also holds_ board certification in

Clinical Supervision through the American Board of Examiners in Clinical
Social Work ( ABE ) _or_ otherwise qualifies to offer Clinical Supervision under the
rules of the Georgia Composite Board of Professional Counselors, Social
Workers, and Marriage and Family Therapists,

- Licensed Marriage and Family Therapist ( LMFT ) _who also holds_ the Approved

Supervisor designation through the American Association for Marriage and
Family Therapy ( AAMFT ),

- Certified Clinical Supervisor ( CCS ) through the Georgia Addiction Counselors

Association ( GACA ) _including_ proof of having taken and passed the NCC AP’s
written Clinical Supervisor examination (“Grandfathered” individuals who did not
take an exam shall not be approved for the provision of Clinical Supervision),
and/or

- National Clinical Supervision Endorsement ( NCSE ) through the National

Association of Alcohol & Drug Abuse Counselors ( NAADAC ).

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.

# Addiction Certification Preparation Program Application

SOP 107.17
Attachment 1

3/31/22
Page 5 of 6

_If the Clinical Supervisor does not hold the ADACBGA CCS and/or IC&RC ICCS but instead_
_holds one of the other acceptable credentials for Clinical Supervisors listed above_, the Clinical
Supervisor must first be approved by the board ahead of the provision of Clinical Supervision to
the candidate, provide documentation of a minimum of two (2) years practice and supervisory
experience specific to substance use treatment and/or the treatment of co-occurring disorders,
and must document a minimum of five (5) hours of co-occurring- or substance use- specific
continuing education hours each year.

_____ I also recognize that I may have to pay out-of-pocket for Clinical Supervision.

_____ I must apply to the certification board and take a computerized test in order to become certified.

I plan to obtain Clinical Supervision from ________________________________________________

Do you have any questions regarding the program requirements?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Applicant’s Signature: _________________________________________ Date:___________________

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.

# Addiction Certification Preparation Program Application

LEADERSHIP SECTION
(WARDEN, DEPUTY WARDEN OF CARE AND TREATMENT, SUPERINTENDENT,

ASSISTANT SUPERINTENDENT, OR CHIEF COUNSELOR)

This section must be completed by one of the Staff listed above.

SOP 107.17
Attachment 1

3/31/22
Page 6 of 6

___Yes ____No In your opinion, is this Applicant sufficiently motivated to complete this lengthy and

demanding program?

___Yes ____No Is this Applicant adequately performing his/her assigned duties on the job?

___Yes ____No Is it feasible for this Applicant to attend training every month for at least three (3)

consecutive days, as well as possible other trainings as needed, to complete the 300
hours of training required to obtain certification?

___Yes ____No Will this Applicant be able to provide 4,000 hours (approximately two (2 )years) of

specific Direct Services (screening, intake, orientation, assessment, case management,
crisis intervention, counseling, consultation, client education, treatment planning,
referral, reports, and record-keeping) to a substance abusing population that has been
identified through a formal assessment and/or an official override?

___Yes ____No Will this Applicant be able to receive the required minimum of 10 hours of Clinical

Supervision in each of the 12 Core Functions as part of the 200 hours needed to
obtain certification?

___Yes ____No Does this Applicant have your endorsement to participate in this program?

Leader’s Signature: ___________________________________ Date: ________________________

_*Please contact the Office of Reentry Services for further clarification of the Addiction_

_Certification Preparation Program (ACPP) requirements._

Retention Schedule: Upon completion, this form shall be retained for a minimum of two (2) years after Staff has become
certified.