Alc/Drug Counselor-- 300 hours Training Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF ALCOHOL AND DRUG COUNSELORS PRACTICAL TRAINING
TO BE COMPLETED BY APPLICANT

APPLICANT: Complete the top portion and forward a copy to the individual(s) who supervised your practical training in alcohol and drug counseling.
Applicant's Name

First NameLast Name
Date of Birth

MonthDayYear
Daytime Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name of person providing verification of supervised practical training.
Enter First and Last Name
Dates of practical training: from

MonthDayYear
to:

MonthDayYear
TO BE COMPLETED BY SUPERVISOR ONLY
The applicant identified above completed practical training under my supervision in alcohol and drug counseling from Date to Date .
Name and address of organization where work experience/internship was completed:
Name and Address of Organization
Total hours of supervised practical training in alcohol and drug counseling completed.
Total Training Hours
Do you have any derogatory information regarding the competency or conduct of this individual?
If yes, please explain:
Enter Explanation
I certify that the above named applicant received a minimum of ten (10) hours of clinical training in each of the following core counseling functions: screening, intake, orientation, assessment, treatment planning, counseling, case management, crisis intervention, client education, referral, report and record keeping, and consultation.

If no, please indicate below the Core Counseling functions not covered by at least 10 hours:

All of the statements contained herein are true and correct to the best of my knowledge and belief.
Name of Person Completing Form
Enter First and Last Name
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
Date

MonthDayYear
This form must be returned directly by the supervisor to the following address:

Department of Public Health
ADC Licensure/Certification
410 Capitol Ave., MS #12APP
P.O. Box 340308
Hartford, CT 06134-0308
Should be Empty: