SOP_NUMBER: 107.17-att-1 TITLE: Addiction Certification Preparation Program Application DIVISION: Unknown TOPIC_AREA: 107 Policy-Counseling/Risk Reduction EFFECTIVE_DATE: 2022-03-31 WORD_COUNT: 1133 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/369699 URL: https://gps.press/sop-data/107.17-att-1/ SUMMARY: This form is an application for GDC staff seeking to become certified addiction counselors through the Addiction Certification Preparation Program. Applicants must document their education, counseling training, work history with substance abuse populations, professional certifications, and commit to completing 4,000 hours of direct service experience, 300 hours of specialized training across 12 core counseling functions, and 200 hours of clinical supervision. KEY_TOPICS: addiction certification, substance abuse counselor, ADACBGA certification, clinical supervision, counselor training, core functions, direct services, substance abuse treatment, chemical dependency, co-occurring disorders, correctional counselor ATTACHMENTS: 1. Addiction Certification Preparation Program Application URL: https://gps.press/sop-data/107.17-att-1/ ======================================================================== FULL TEXT: ======================================================================== # **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.