Fillable PCB CADC Application 19 0

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PCB CADC Application 19 0

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PCB CADC Application | Revised October 2019
298 S. Progress Avenue, Harrisburg, PA 17109
Phone: 717-540-4455 Fax: 717-540-4458
www.pacertboard.org info@pacertboard.org
CADC APPLICATION
Certified Alcohol and Drug Counselor
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
2
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to submitting your application, you must have all requirements completed and
documented. Use the table below as a guide for gathering your documentation.
Do not submit any documentation with your application that is not listed on the table or the
application unless specifically instructed by a staff member. Do not submit your application
until you have completed the application requirements.
REQUIREMENT DOCUMENTATION
✓
Application Page with payment
• Page 7
Experience & Supervision Information
• Page 8
• Previous relevant employment documentation
(if needed).
Current Job Description
• Obtain from employer.
Supervision Documentation Form
• Page 9
Education
• Official transcripts sent directly to Board
•
Copies of trainings (if applicable)
Acknowledgement & Release
• Page 10, notarized
Disciplinary Actions?
• Include letter of explanation with application.
Convicted of a felony?
• Include letter of explanation with application.
Company paying fee?
• Include applicant name on payment.
Copy entire application for records
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org
NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not
indicate it has been received. To confirm receipt of your application, email info@pacertboard.org
.
REVIEW & APPROVAL PROCESS
1. Application submitted to the Board. To confirm receipt of your application, you must email the
Board at the above email address.
2. Staff reviews application. Allow 5- 10 business days for review and processing of your
application.
3. Applicant will be emailed if there is any documentation missing from the application or there
are questions regarding your application. It is imperative that you write your email legibly.
4. Your application is considered approved when you receive an email to register for the
examination.
5. Follow all instructions to register for the examination provided to you in the email.
6. If you have not heard from the Board regarding your application or received an email to register
for the examination after 10 business days, email info@pacertboard.org
.
7. Once you pass the examination, you are certified.
8. A certificate will be mailed to you automatically within 5-10 business days.
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
3
APPLICATION INFORMATION
APPEAL PROCESS
The purpose of appeal is to determine if the Board accurately, adequately and fairly reviewed an
application that is denied. A letter requesting an appeal must be sent to the Board in writing within 30
days of the notification of the Board's action. An applicant shall be considered notified three days after
the relevant date of mailing. The written appeal will be sent to the Executive Committee who in turn will
thoroughly review the entire application and materials to determine whether or not applicant should
have been denied approval. The applicant will be notified in writing as to the findings of the Executive
Committee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the applicant passes the
examination. The certificate issued to the professional lists the following information: name of
professional, credential name, date of issue, date of expiration and certification number.
FELONIES & DISCIPLINARY ACTIONS
While felonies and disciplinary actions from other certification/licensing entities may not prohibit
certification, documentation is required to be submitted at the time of application. Certification through
the Board does not mean a professional should not disclose this information to potential employers and
does not in any way exonerate charges.
INTERNATIONAL CERTIFICATES
A seal will be added to your certificate indicating the international status of your certification. The
International Certificate provides recognition of your status as an internationally certified substance use
disorder professional. Original International Certificates are available for a fee directly from IC&RC at
www.internationalcredentialing.org
. PCB does not issue international certificates.
REQUESTS TO CHANGE APPLICATION
Professionals who wish to have their application re-reviewed for another credential the Board offers
prior to taking the examination, or after an unsuccessful attempt at the examination will incur a $50
application change/review fee.
RECERTIFICATION
To maintain the high standards of professional practice and to assure continuing awareness of new
knowledge in the field, the Board requires recertification every two years. Professionals should review
the Recertification Application for credential specific requirements listed on the Board website well in
advance of their expiration date.
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
4
EXAMINATION INFORMATION
TYPE OF EXAMINATION
The successful completion of an IC&RC exam is required. The examination is a computer based, 150
multiple-choice questions and offered on an on-demand basis at an approved testing site. There are
several sites in the state. Candidates may choose the day, time and site.
TIME PERMITTED
Three hours are permitted to complete the examination.
EXAMINATION CONTENT
The examination is developed from the IC&RC Job Analysis which identify domains and tasks for
competent practice.
CANDIDATE GUIDE
The domains, including the task statements per domain, sample exam questions, and a list of references
from the IC&RC Job Analysis are included in the free Candidate Guide. Candidate Guides are available
from the Board website.
STUDY MATERIAL
Professional study guides and practice exams have been published for the examination. Visit IC&RC’s
website for more information: www.internationalcredentialing.org
.
SPECIAL SITUATIONS & ACCOMMODATIONS
Individuals with disabilities and/or religious obligations that require modifications in examination
administration may request specific procedure changes in writing with official documentation to the
Board no fewer than 60 days prior to their examination date. Contact the Board on what constitutes
official documentation. The Board will plan for appropriate modifications to its procedures when
documentation supports this need.
CANCELLATION/RESCHEDULING POLICY
Candidates are required to arrive on time for their examination. Candidates who arrive late will not be
permitted to take the examination and will be charged a $175.00 cancellation/rescheduling fee.
Candidates who cancel or reschedule their examination less than five days prior to their scheduled date
will be charged the full examination fee. Candidates who cancel or reschedule more than five days
before their scheduled date will be charged a $25.00 cancellation/rescheduling fee.
RETESTING
Candidates who fail the examination can retest after a 90 day wait period from the date of their last
examination. Candidates will be sent instructions and fee information. Candidates have three (3)
opportunities to retake an examination. If a candidate fails the examination four (4) times they must
submit a study plan and wait one-year from the date of the final failed examination before they will be
permitted to retest again.
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
5
CERTIFIED ALCOHOL & DRUG COUNSELOR REQUIREMENTS
Prior to submitting your application, applicants must have all requirements completed and
documented.
DEGREE
The degree must be from an accredited college/university that is recognized by the US Department of
Education or the Council on Higher Education Accreditation. An official transcript sent directly from
college/university is required. If the degree is from outside the United States a degree equivalency must
done by an organization that specializes in that process. The applicant is responsible for arranging this
process and all costs.
Official transcripts are required and must be sent directly from college/university to the Board office. If
your college/university uses an e-transcript system, they can be emailed directly to the Board. It is
recommended you request transcripts approximately three weeks prior to sending in your
application.
• Minimum Bachelor’s degree is required.
EXPERIENCE & SUPERVISION
Qualifying experience is defined as providing primary, direct, clinical, substance use disorder or co-
occurring counseling to persons whose primary diagnosis is that of substance use disorder or providing
supervision of said counseling. Applicant must have primary responsibility for providing substance use
disorder counseling in an individual and/or group setting, preparing treatment plans, documenting client
progress and is clinically supervised. Examples of positions that typically are not approved include: case
managers, technicians, peer and recovery counselors/specialists, intake, admissions, etc.
The applicant must be currently employed in the qualifying position at the time of application. Only
employment within the last seven (7) years may be counted towards the total experience requirement.
If the applicant’s experience requirement is not fulfilled from their current employer, they must include
a letter (on company letterhead) from previous employer(s) verifying their duties and dates employed
with their application.
• Experience: Bachelor’s degree in a relevant field: two (2) years of full-time employment or 4000
hours of part-time of employment.
• Experience: Bachelor’s degree in a non-relevant field: three (3) years of full-time employment or
6000 hours of part-time employment.
Supervision is a formal or informal process that is evaluative, clinical, and supportive. It can be provided
by more than one person, it ensures quality of clinical care, and extends over time. Supervision includes
observation, mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self-
motivation, learning, and professional development. In all aspects of the supervision process, ethical and
diversity issues must be in the forefront.
• Supervision: 200 hours with a minimum of 10 hours in each domain. Hours may be included in
the total experience requirement.
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
6
CURRENT JOB DESCRIPTION
All applicants must include their current job description with their application. This document is
provided by your employer and must be signed and dated by you and your supervisor. Job descriptions
are reviewed as a part of experience verification. If your supervisor does not have your job description,
you should contact your organization’s Human Resource department. The Board does not provide the
job description.
• Current job description: obtained from employer.
EDUCATION
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-
services, college/university credit courses and online education. If you provide this type of education to
other professionals, you may use it towards the education requirement with documentation from the
organization or college/university. Most three-credit college/university courses are 45 hours. There is no
time limit on the use of education for initial certification.
Education review is available prior to application submission with the use of the Education Review Form
on the Board website.
• Education: 300 total hours of education relevant to the field of substance use disorders.
o 100 of the hours must be substance use disorder specific
o Six (6) of the hours must be in professional ethics and responsibilities that are
specific to behavioral health. Ethics courses that are in business, philosophy,
religion, etc. are not accepted.
EXAMINATION
Applicant must pass the IC&RC Examination for Alcohol and Drug Counselors.
• Domains
1. Screening, Assessment, & Engagement
2. Treatment Planning, Collaboration, & Referral
3. Counseling
4. Professional & Ethical Responsibilities
FEES
The application fee may be paid by check, money order or with VISA, MasterCard, Discover or American
Express. One-half of the application fee is refundable if application is denied or cancelled prior to the
examination. No refund will be issued if application is denied or cancelled after examination. If an
employer or organization is paying the application fee, they must include the applicants name with the
payment. Failure to include the applicants name will result in delay in approval of the application.
• Application Fee: $375 (fee must accompany application and materials)
• Retest Fee: $175
• Exam Cancellation Fee: $175
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
7
PCB APPLICATION FOR CADC
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
Date:
DOB:
□ Male
□ Female
□ Self-identify _____________________
Name:
SSN: (last four)
Print your name as it should appear on your certificate. Credentials and degrees will not be printed.
Home Address:
City:
State:
Zip:
Email:
Cell Phone:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
Have you ever received any disciplinary action from another certification/licensing authority? □ Yes □ No
If yes, provide full details on a separate sheet.
Have you read and understood the PCB Code of Ethical Conduct? □ Yes □ No
The Code of Ethical Conduct is located at www.pacertboard.org, and click on Ethics.
Military Experience: □ Not Applicable □ Active □ Veteran
Ethnicity: □ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic □ Latino
□ Native Hawaiian or Other Pacific Islander □ Not specified: ______________________
Employment plans for the next two years: □ Increase Hours □ Decrease Hours □ No Change □ Seek Advancement
□ Retire □ Move to a different career □ Unknown
PAYMENT INFORMATION
FEE OF $375 CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email for receipt (if paying by credit card only): ________________________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
8
CADC APPLICATION: EXPERIENCE & SUPERVISION INFORMATION
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Do you need to document previous employment to fulfill the experience requirement? □ Yes □ No
If yes, complete the section below AND submit a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed
must be included with your application.
DO NOT SUBMIT A RESUME WITH YOUR APPLICATION. IT WILL NOT BE REVIEWED AND IT DOES NOT FULFILL THE
DOCUMENTATION REQUIREMENT FOR EXPERIENCE.
CURRENT SUPERVISOR INFORMATION
Immediate Supervisor Name:
Email:
Phone:
Do you have more than one supervisor or need to document supervision from a previous employer? □ Yes □ No
If yes, provide copies of the CADC Application: Supervision Documentation Form (page 9) to all supervisors. Multiple supervision forms can be
submitted with your application.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE) – LETTER (ON COMPANY LETTERHEAD) FROM
PREVIOUS EMPLOYER(S) VERIFYING YOUR DUTIES & DATES EMPLOYED MUST BE INCLUDED WITH YOUR APPLICATION.
Organization Name:
How many hours did you work per week? ______________________________________________________
Organization Name:
How many hours did you work per week? ______________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Hire Date in Current Position:
Supervisor Position/Title:
Average Number of Hours of Supervision Received Per Week:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
9
CADC APPLICATION: SUPERVISION DOCUMENTATION FORM
Form to be completed by Applicant’s current and/or previous clinical supervisor(s).
This form is not intended to document all experience or supervision hours of the applicant, rather the minimum hours
required for the certification. Please note: the standard hours accepted for clinical supervision is two (2) hours per week.
If you document more than that for the applicant (your supervisee) you will need to provide documentation to the
Board for the hours to be accepted. This will delay the approval of your supervisee’s application.
Supervision is a formal or informal process that is evaluative, clinical, and supportive. It can be provided by more than
one person, it ensures quality of clinical care, and extends over time. Supervision includes observation, mentoring,
coaching, evaluating, inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional
development. In all aspects of the supervision process, ethical and diversity issues must be in the forefront.
Applicant Name:
CLINICAL SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
CLINICAL SUPERVISION DOCUMENTATION
Clinical Supervision was provided in the following Domains (check all that apply):
DOMAIN:
NUMBER OF HOURS:
□ Screening, Assessment, & Engagement
□
Treatment Planning, Collaboration, & Referral
□ Counseling
□
Professional & Ethical Responsibilities
Supervisor Attestation:
I attest that the above-named applicant is providing primary, direct, clinical, substance use disorder or co-occurring
counseling to persons whose primary diagnosis is that of substance use disorders or providing supervision of said
counseling. They have primary responsibility for providing counseling in an individual and/or group setting, preparing
treatment plans, documenting client progress and is clinically supervised. Current employers: I have provided the
applicant with their job description, reviewed it with them, signed and dated it. Previous employers (if applicable): I
have provided the applicant with a letter (on company letterhead) listing and verifying their duties and dates employed.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF CLINICAL SUPERVISION:
click to sign
signature
click to edit
PCB CADC Application | www.pacertboard.org | info@pacertboard.org | Revised October 2019
10
CADC APPLICATION ACKNOWLEDGEMENTS & RELEASE
This page must be completed by the applicant. It must be notarized and submitted with the application.
RELEASE
I request that the Pennsylvania Certification Board (PCB) grant the credential to me based on the following assurances
and documentation:
• I subscribe to and commit myself to professional conduct in keeping with the PCB Code of Ethical Conduct;
• I certify that the information given herein is true and complete to the best of my knowledge and belief. I also
authorize any necessary investigation and the release of information relative to my credential. Falsification of
any documents will nullify this application and will result in denial or revocation of certification;
• I consent to the release of information contained in my application and any other pertinent data submitted to or
collected by PCB to officers, members, and staff of the aforementioned Board;
• I consent to authorize PCB to gather information from third parties regarding education and employment and
understand that such communication shall be treated as confidential;
• Allegations of ethical misconduct reported to PCB before, during, or after application for certification is made
will be investigated by PCB and could result in the nullification of the application or denial or revocation of
certification.
INITIAL EACH STATEMENT
I have read and understood the Release.
I either live or work in Pennsylvania at least 51% of the time.
I understand one-half of the application fee is refundable if application is denied or cancelled prior to the
examination and no refund will be issued if application is denied or cancelled after examination.
I understand that my application is open for a period of one year after the date of review. If I fail to fulfill all
certification requirements within that year, the application will be closed, and no refund will be issued.
I understand that if I request to have my application re-reviewed for another credential PCB offers prior to
the examination, or after an unsuccessful attempt at the examination I will incur a $50 change/review fee.
Applicant:
Signature:
Date:
PRINT NAME LEGIBLY
NOTARY PUBLIC ONLY
Name:
Date:
I attest that I am a notary public and the above-named applicant satisfactorily proved to be the person whose name is
subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereby set my hand and official seal.
__________________________________________________ SEAL:
Notary Public Signature
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PCB CADC Application 19 0

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Completed 28 January 2021

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