Substance Abuse Counselor: Supervised Training Verification

Public Health: Verification Of Alcohol And Drug Counselors Practical Training

DPH Data Management and Governance (PLIS)
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
Day Time Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Name of person providing verification of supervised practical training:
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 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
Total hours of supervised practical training in alcohol and drug counseling completed:
Do you have any derogatory information regarding the competency or conduct of this individual?
If yes, please explain:
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:

Rows	Please check all that applies	Hours Provided
screening
intake
referral
orientation
assessment
treatment planning
report and record keeping
counseling
case management
crisis intervention
consultation
client education

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
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:

Public Health: Verification Of Alcohol And Drug Counselors Practical Training