Csc Spv User Credentials Form – Fill Out and Use This PDF

SECTION 6. CLINICAL EXPERIENCE (please duplicate this page for each different employer or volunteer agency)

•You will need to document 6,000 hours (three years) of clinical experience, AND

•You will need to document 2,000 hours (one year) of experience as an AOD supervisor (may be included in total clinical experience).

•You may substitute or supplement your clinical experience with a degree or experience teaching in an AOD program (see Section 7).

Applicant Name

Your Title or Position with the Agency / Organization

Name of Supervisor

Title / Position of Supervisor

Agency / Organization

Address (Number, Street, Apartment or Suite Number)

City

E-mail Address

Web Site Address

Dates and hours associated with AOD and/or supervisor activities within this organization (full time equals 2,000 hours per year):

Job Description:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Attestation of Agency / Organization Representative: I attest the above information is true and correct.

SECTION 7. CLINICAL EXPERIENCE SUBSTITUTE (please duplicate this page for each different educational institution) Complete this section if you are seeking to substitute or supplement the Clinical Experience requirement (identified in Section 6) with your experience teaching a course or courses within the healing arts or related field at an approved or accredited institution of higher learning. You may substitute ten (10) hours of Clinical Experience for each hour of class that you have taught. (PLEASE NOTE: MUST HAVE A MINIMUM OF 2,000 HOURS – or 1 YEAR – OF ACTUAL CLINICAL AND / OR SUPERVISOR EXPERIENCE.)

Applicant Name

Your Title or Position at Educational Institution

Name of Supervisor or Department Head

Title / Position of Supervisor or Department Head

Educational Institution

Address (Number, Street, Apartment or Suite Number)

City

E-mail Address

Web Site Address

Course Name(s) dates, and hours taught at this institution:

Attestation of Educational Institution Representative: I attest the above information is true and correct.

SECTION 8. PROFESSIONAL REFERENCES (please duplicate this page for each reference)

A total of three references from professionals in the field of addictions who can attest to your proficiency in the field:

•One reference must be from a supervisor of your work, or from a colleague in the healing arts field; AND

•Two references must be from professionals in the general field of addictions, who know of your work in the field.

Applicant Name

Name of Professional Reference

Relationship of Professional Reference to Applicant (Supervisor, Colleague or Addiction Professional)

Title / Position of Reference

Agency / Organization

Address (Number, Street, Apartment or Suite Number)

City

E-mail Address

Web Site Address

Please explain why you believe that the Applicant should be awarded the Clinical Supervisor Credential (CSC):

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

SECTION 9. CODE OF ETHICS

You are required to maintain compliance with the Code of Ethics for CSC Professionals. Sign this Code of Ethics at the space provided below.

Clinical Supervisor Credential (CSC)

CODE OF ETHICS

As a Clinical Supervisor Credential (CSC) professional, I will comply with this Code of Ethics and do affirm:

That my primary goal is recovery for the client and the client’s family, through conducting my role as a supervisor in a professional and caring manner.

That I have a total commitment to provide the highest quality of supervision to those whom I am committed to providing supervision. That I shall not provide services beyond the terms and conditions of my professional certifications and/or licenses.

That I shall evidence a genuine interest in all of the individuals that are supervised by me, and do hereby dedicate myself to the best interest of my agency and supervisees, and to help them help themselves.

That I shall maintain at all times an objective, professional relationship with all of my supervisees.

That I shall adhere to the Rule of Confidentiality with regard to all records, material and knowledge concerning my client, and shall protect his/her rights to confidentiality in accord with Code of Federal Regulations, Title 42 sections 2.1 through 2.67(1) and any other applicable regulations.

That I shall cooperate with complaint investigation and supply information requested during such complaint investigations, subject to the confidentiality provisions cited above.

That I shall not in any way discriminate between clients or fellow professionals on the basis of race, religion, age, gender, disability, national ancestry, sexual orientation or economic condition.

That I shall respect the rights and views of my fellow counselors and other addiction professionals. I will not verbally, physically or sexually harass, threaten, or abuse any program participant, patient, client or fellow addiction professional.

That I shall maintain respect for institutional policies and management within agencies, and will take the initiative toward improvement of such policies and management when it will better serve the interests of my supervisees.

That I have a continuing commitment to assess my own personal strengths, limitations, biases and effectiveness.

That I shall continuously strive for self-improvement and professional growth through further education and training.

That I have an individual responsibility for my own conduct in all areas, including, but not limited to, the use of mood-altering drugs. I shall not provide supervision, counseling or education services while under the influence of any amount of alcohol or illicit drugs (not including drugs or medication prescribed by a physician or other person authorized to prescribe drugs, used in the dosage and frequency prescribed; nor including over-the-counter medications used in the dosage and frequency described on the box, bottle or package insert).

That I have an individual responsibility for myself in regard to sexual conduct and/or contact with fellow counselors, supervisors, supervisees, and clients, and shall not engage in sexual conduct with current program participants, patients or clients.

These things I pledge to my professional peers and to my supervisees.

I hereby pledge to comply with this Code of Ethics, as well as to comply with a consistent code of conduct that may be applicable to a recovery or treatment program with which I may be affiliated.

SECTION 10. PHOTOGRAPH

Include a recent photograph of yourself. This photo will be used by Breining Institute to identify you. Write your full name on the back of the photo, which may be any size between 1” x 2” and 8” x 10”. We will keep your photo in your file, and it will not be returned.

If yes, please explain: ________________________________________________________________________________________________

SECTION 12. DOCUMENTATION. Please check all that are applicable to your Application:

Currently licensed or certified professional

I attest that I am a currently licensed and/or certified addiction professional:

Expiration date of current license or certificate (Month – Day – Year)

Title of license or certificate

r

License or certification number

Name of licensing or certifying agency

Web site address of licensing or certifying agency

Documentation included with this Application (please check all that apply)

Documentation of 40 hours in courses related to clinical supervisor competencies (certificates of completion, transcripts, etc.).

If applicable, documentation of Degree (copy of or official transcripts are acceptable).

Clinical Experience documentation: Use one “Section 6” page for each employer or volunteer agency.

Clinical Experience Substitute documentation, if applicable: Use one “Section 7” page for each educational institution.

Three Professional References: Use one “Section 8” page for each reference. Be sure to include one supervisor and two other references.

Signed Code of Ethics: Sign and date the Code of Ethics located at the “Section 9” page.

Current photograph, with your full name written on back.

Copy of current addiction professional license or certificate.

Copy of Breining Institute “Private-practice / Clinical Supervisor (PCS) Exam” Score Report.

ATTESTATION OF INFORMATION AND DOCUMENTATION

The undersigned Applicant declares that the information provided in the Application and within the supporting documentation is true and authentic. I intend to comply with the provisions of the CSC Code of Ethics. The Applicant understands that if at any time it is shown that the information or documentation provided is not true or is misrepresented, any fees which have been paid will be forfeited by Applicant, and certification as a CSC may be revoked.

Return this completed Application and supporting Documentation by postal mail, fax or e-mail to:

Breining Institute

8894 Greenback Lane

Orangevale, California USA 95662-4019

Fax: 916-987-8823

E-mail: College@Breining.edu

Questions?

Please call us at 916-987-2007