Substance Abuse Counselor: Experience/Internship Verification

Public Health: Verification Of Alcohol And Drug Counselors Work Experience Or Internship

DPH Data Management and Governance (PLIS)
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
Day Time 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:
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:
If work experience/internship was completed outside of Connecticut, please check one of the following as appropriate: I am licensed in the state in which the work experience/ internship was completed to practice:
State:
License #
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 of organization where work experience/internship was completed:
Address of organization where work experience/internship was completed:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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:
weeks per year:
Number of hours considered to be full-time at employment site:
Total number of hours completed as a part of work experience/internship:
Of the total hours completed, how many hours were in the counseling core function?
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:
Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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:

Public Health: Verification Of Alcohol And Drug Counselors Work Experience Or Internship

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY SUPERVISOR

DETAILS OF WORK EXPERIENCE/INTERNSHIP