Alc/Drug Counselor -- 3 Years Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF ALCOHOL AND DRUG COUNSELORS WORK EXPERIENCE OR INTERNSHIP
TO BE COMPLETED BY APPLICANT

APPLICANT: Complete this portion and forward a copy to the appropriate organization(s) where you completed paid work experience or an unpaid internship.
Applicant's Name

First NameLast Name
Date of Birth

MonthDayYear
Daytime Telephone
Please enter a valid phone number.Format: (000) 000-0000.
TO BE COMPLETED BY SUPERVISOR

SUPERVISOR’S CREDENTIALS

Note: In order to qualify as an acceptable supervisor, individuals other than A&DCs must have completed 50 hours of specialized alcohol and drug counseling education in the areas of pharmacology, assessment and treatment planning, and treatment techniques and have experience working directly with persons who have been assessed or diagnosed as having an alcohol or other drug abuse dependency.
Name & Title
Name and Title
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If work experience/internship was completed in Connecticut, please check one of the following as appropriate:
License/Certification Number
License or Certification Number
Name of Professional Title
Name of Professional Title
If work experience/internship was completed outside of Connecticut, please check one of the following as appropriate:
Check if Yes.
State
State
License Number
License number
DETAILS OF WORK EXPERIENCE/INTERNSHIP
This is to verify that the applicant identified above completed work experience/internship under my supervision from Date to Date .
Name and address of organization where work experience/internship was completed:
Organization Name and Address
Type of experience being verified? (Check one)
Did the experience include working directly with persons who have been assessed or diagnosed as having an alcohol or other drug abuse dependency and providing specific counseling interventions that are directed toward the amelioration of a substance use disorder and that are identified in a treatment plan and encompass all of the core counseling functions?
Hours worked per week
Number of Hours
Weeks per year
Number of Weeks
Number of hours considered to be full-time at employment site
Number of Hours
Total number of hours completed as a part of work experience/internship
Number of Hours
Of the total hours completed, how many hours were in the counseling core function?
Number of Hours
I certify that I qualify as an acceptable supervisor in accordance with the requirements identified above and that 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
Thank you for your assistance. This form must be returned directly by the verifying authority to:

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

STATE OF CONNECTICUT

VERIFICATION OF ALCOHOL AND DRUG COUNSELORS WORK EXPERIENCE OR INTERNSHIP