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
Enter 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
I am a Connecticut licensed alcohol and drug counselor.I am certified as a Clinical Supervisor by the Connecticut Certification Board.I am licensed in Connecticut as a (Professional Title), and am qualified as an acceptable supervisor as stated above.
License/Certification Number
License or Certification Number
Name of Professional Title
Name of Professional Title
alcohol & drug counselingregistered nursingmedicine and surgerypsychologyclinical social workprofessional counselingmarital and family therapyadvanced practice registered nursing
I am licensed in the state in which the work experience/internship was completed to practice.
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
Paid Work ExperienceUnpaid Internship
YesNo
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
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