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					        MARYLAND BOARD OF PROFESSIONAL COUNSELORS & THERAPISTS
                           4201 PATTERSON AVE.
                             Baltimore, MD 21215
                         410-764-4732 – Main Number
                     410-764-4740 – Licensure Coordinator
                              410-358-1610 – Fax
                          www.dhmh.state.md.us/bopc/

                            CAC-AD APPLICATION INSTRUCTIONS

    COUNSELORS AT THIS CERTIFICATION LEVEL MAY APPLY FOR
         APPROVED SUPERVISOR STATUS AFTER 2 YEARS.
1. Application: Must be completed in full. Your photograph must be attached to page 4. The application must
   be notarized, page 4.

2. Fees – Application Fee of $75.00 must be submitted with the application. At the time of approval,
   $100.00 certification fee is required. Fees are non-refundable. Make your check payable to the
   “Board of Professional Counselors and Therapists.”

3. Education – Bachelor’s degree from an accredited college in a health or human services counseling field. 21
   credits in alcohol and drug counseling and 1-credit ethics with a focus on alcohol and drug counseling.

4. Supervised Experience- 3 years with 2,000 hours. 2 years and 2,000 hours after the awarding of the
   Bachelor’s degree.

5. Professional References – Three professional references are required. Reference forms are
   enclosed.

6. Examination – Applicants must pass the ICRC/AODA Examination and Maryland State Law Test.
   The ICRC is administered by computer in Belair, Columbia, and Annapolis. The Law Test is
   administered twice a month at the Board's office. In order to sit for the examinations, all applicants
   must meet the education and supervision requirements in #3 and #4 above.
                     Maryland Board of Professional Counselors and Therapists
                                     4201 Patterson Avenue
                                 Baltimore, MD 21215 3rd Floor
                                          410-764-4732
                                             www.dhmh.state.md.us/bopc/

                                                APPLICATION

               Certified Associate Counselors Alcohol and Drug (CAC –AD)
           COUNSELORS AT THIS CERTIFICATION LEVEL MAY APPLY FOR
                APPROVED SUPERVISOR STATUS AFTER 2 YEARS.

                                                                              APPLICATION DATE:


 General Information:


                               NAME AND CONTACT INFORMATION

                  Dr.         Mr.      Ms.
1. Name:          Mrs.

2. Maiden or Previous Name, if different from above:

3. Address:
                     Street                             City              County    State         Zip Code
4. E-Mail Address:

5. Social Security Number:                                5. Date of Birth:
6. Telephone Number:
                                     Home                         Work

 I am applying for certification as a :
     Certified Associate Counselor, Alcohol and Drug(CAC-AD)

 Section I.
                                        Academic History and Credentials
 Criteria:
 CAC –AD – Bachelors Degree in a Health or Human Services Counseling field.
 Directions: Please list your relevant educational history below, beginning with your most recent college
 education. Official Transcripts are required.
 College or University                  Date(s) of Attendance                 Degree Awarded/Major




                                                                                                             2
     SECTION II. Supervised Experience in Alcohol and Drug Counseling
     Criteria: 3 years, minimum 2,000 hours, 2years must be after the award of degree.

     Directions: List your experience in Alcohol and Drug Counseling. Begin your current or most recent
     experience. Provide dates of employment (month/year beginning and ending), agency/ employer, and
     supervisor’s name and position title.
                                                  Pre-Degree
fs       Dates                     Agency/Employer                Supervisor             Position Title




     Dates                         Agency/Employer            Supervisor                 Position Title




                                                Post Degree

       Dates                       Agency/Employer            Supervisor                 Position Title




        Dates                         Agency/Employer             Supervisor                  Position Title




      Documentation: You must provide written documentation for employment listed above.
      Acceptable documentation includes letter(s) from supervisors, from personnel departments.
                                                                                                          3
SECTION III.
                                                    Examination
All applicants must pass the ICRC/AODA written examination and Maryland State Law Test

I have passed the ICRC/AODA examination        Yes               No
If you have passed the ICRC/AODA examination, please include official results.

I have passed the Maryland State Law Test          Yes              No
If No, you must meet the education requirements before you will be authorized to take the ICRC or Law Test.

                                              Additional Information

A.         Have you ever been denied initial application reinstatement or renewal of a license and/or certification by
           any state licensing or disciplinary board?      Yes No
     If “yes” explain reasons

B.         Has any state licensing or disciplinary board ever taken any action against your license and/or
           certification, including but not limited to limitations of practice, required education, admonishment,
           reprimand, revocation, suspension?         Yes      No
     If yes, explain circumstances

C.         Has an investigation or charge ever been brought against you by any licensing or
          Disciplinary board?       Yes No
     If yes, please explain

D.        Have you pled guilty, nolo contendre, or been convicted of or received probation before
          Judgment of any criminal act (excluding traffic violations)?     Yes            No
          If “yes” provide the following information: Date of conviction:
          Where convicted:                   Charge:
          If conviction was set aside, give date and explain using additional pages if necessary. Include required
          information on all felony convictions attaching additional sheets if necessary.

E.        Are you currently an Alcohol and Drug Counselor Trainee?         Yes     No

           If “yes”, when does your “Trainee Status” expire? _____/____/____
                                                              (mm/dd/yyyy)
         Are you currently a CSC-AD?      Yes      No


F.      Are you currently licensed as an (check appropriate box) LCPC?           LGPC?     LCMFT?        LGMFT?
              None of the above

G.       Are you currently licensed by another Maryland Board in Mental Health Counseling?            Yes     No

            If yes, please specify license held (Ex: LCSW-C, LGSW, Psychologist) ________________



                                                                                                                    4
                                                     AFFIDAVIT

In making this application to the Maryland Board of Professional Counselors and Therapists for the issuance of a
license, I agree to abide by the rules and regulations of the Maryland Board of Professional Counselors and
Therapists and to take all examinations necessary to the processing of my application. Upon issuance of a
license, I agree to be bound by the Code of Ethics. I further understand that the fee submitted with this
application is non-refundable.

I agree to hold the Maryland Board of Professional Counselors and Therapists, its members, officers, agents, and
examiners free from any damage or claim for damage or complaint by reason of any action they or any one of
them take in connection with this application, the attendant examination, the grades with respect to any
examination, and/or failure of the Board to issue me a license. I hereby grant permission to the Board to seek any
information or references it deems fit in securing my credentials pertinent to this application.

I understand, by law, it is my responsibility to notify the Board in writing if I change my address of residence.

Signed __________________________________

Date: ___________________________________

                                                          NOTARY
State of ____________________________________


City/County of ______________________________


I HEARBY CERTIFY that on this ____________ day of __________________, before me, a Notary Public of the State and
City/County aforesaid, personally appeared ______________________________
__________________________________________, and made oath in due form that the contents of the foregoing Affidavit are true.


Notary Public __________________________________________
Commission Expires ____________________________________




     ATTACH YOUR PHOTOGRAPH
     IN THIS AREA (RECENT 2”x2”)




                                                                                                                          5
                       PROFESSIONAL REFERENCE ASSESSMENT FORM CAC-AD


 Applicant’s Name:
The applicant must complete items 1 and 3
The person named above has applied to the Maryland Board of Professional Counselors & Therapists to become
a State Licensed Professional Counselor. Your assessment of the applicant’s characteristics will enable the Board
to evaluate whether this applicant meets its standards. Please respond to all questions to the best of your ability.
(Questions 1,2 and 3 apply to reference). PLEASE RETURN COMPLETED FORM TO THE APPLICANT
IN A SEALED ENVELOPE.
  1.   Reference’s Name :                                  Profession:
       Business Address:                                   Degree:
                                                           Position Title:
                                                           Telephone:
   2. Professional Certification or License:
       State or Certifying Organization:
   3. Relationship with applicant:
        Trainer or Educator                                Supervisor (Be sure to complete #5 on reverse side)
       Professional Colleague                              Other

 Length of time you have known this applicant: Dates from                    to

4. Please rate the applicant compared to other counselors you know on the following characteristics. Place
a check in every category. (Counselor Educators should be evaluated on the basis of their ability to train
students to counseling skill areas).

                                           Outstanding    Above         Average     Below       Poor Cannot
                                                         Average                   Average           Evaluate
 Individual Counseling skills
 Appropriate referral making skills
 Group counseling skills
 Personal integrity
 Consulting skills
 Insight into client’s problems
 Ability to relate to co-workers
 Ability to be objective on the job
 Ethical conduct
 Concern for welfare of clients
 Sense of responsibility
 Recognition of own limits
 Supervisory abilities
 Ability to keep material confidential



                                                                                                                 6
5. Recommendation: I recommend this application for certification as a Certified Associate Counselor
Alcohol and Drug(CAC-AD)
                             Yes                  No


  Additional Comments:




6. The above information is based upon my best judgment. I am willing to answer additional questions
concerning this evaluation if the Board deems it necessary.



______________________________                                           ______________________
Signature of Reference                                                    Date

After completing this form, please enclose it in a sealed envelope, sign the sealed flap and return it to this
applicant.




                                                                                                            7
                     PROFESSIONAL REFERENCE ASSESSMENT FORM CAC-AD

 Applicant’s Name:



The applicant must complete items 1 and 3
The person named above has applied to the Maryland Board of Professional Counselors & Therapists to become
a State Licensed Professional Counselor. Your assessment of the applicant’s characteristics will enable the Board
to evaluate whether this applicant meets its standards. Please respond to all questions to the best of your ability.
(Questions 1,2 and 3 apply to reference). PLEASE RETURN COMPLETED FORM TO THE APPLICANT
IN A SEALED ENVELOPE.
   1. Reference’s Name :                                   Profession:
       Business Address:                                   Degree:
                                                           Position Title:
                                                           Telephone:
   2. Professional Certification or License:
      State or Certifying Organization:
   3. Relationship with applicant:
        Trainer or Educator                                Supervisor (Be sure to complete #5 on reverse side)
       Professional Colleague                              Other

 Length of time you have known this applicant: Dates from                      to

4. Please rate the applicant compared to other counselors you know on the following characteristics. Place
a check in every category. (Counselor Educators should be evaluated on the basis of their ability to train
students to counseling skill areas).

                                          Outstanding      Above             Average    Below Poor Cannot
                                                          Average                      Average     Evaluate
 Individual Counseling skills
 Appropriate referral making skills
 Group counseling skills
 Personal integrity
 Consulting skills
 Insight into client’s problems
 Ability to relate to co-workers
 Ability to be objective on the job
 Ethical conduct
 Concern for welfare of clients
 Sense of responsibility
 Recognition of own limits
 Supervisory abilities
 Ability to keep material confidential
                                                                                                                 8
5. Recommendation: I recommend this application for certification as a Certified Associate Counselor
Alcohol and Drug(CAC-AD)
                             Yes                  No

  Additional Comments:




6. The above information is based upon my best judgment. I am willing to answer additional questions
concerning this evaluation if the Board deems it necessary.



______________________________                                           ______________________
Signature of Reference                                                    Date

After completing this form, please enclose it in a sealed envelope, sign the sealed flap and return it to this
applicant.




                                                                                                            9
                      PROFESSIONAL REFERENCE ASSESSMENT FORM CAC-AD

 Applicant’s Name:

The applicant must complete items 1 and 3
The person named above has applied to the Maryland Board of Professional Counselors & Therapists to become
a State Licensed Professional Counselor. Your assessment of the applicant’s characteristics will enable the Board
to evaluate whether this applicant meets its standards. Please respond to all questions to the best of your ability.
(Questions 1,2 and 3 apply to reference). PLEASE RETURN COMPLETED FORM TO THE APPLICANT
IN A SEALED ENVELOPE.
   1. Reference’s Name :                                  Profession:
       Business Address:                                  Degree:
                                                          Position Title:
                                                          Telephone:
   2. Professional Certification or License:
      State or Certifying Organization:
   3. Relationship with applicant:
        Trainer or Educator                               Supervisor (Be sure to complete #5 on reverse side)
       Professional Colleague                             Other


 Length of time you have known this applicant: Dates from                   to


4. Please rate the applicant compared to other counselors you know on the following characteristics. Place
a check in every category. (Counselor Educators should be evaluated on the basis of their ability to train
students to counseling skill areas).
                                     Outstanding    Above       Average       Below        Poor Cannot
                                                   Average                  Average                 Evaluate
 Individual Counseling skills
 Appropriate referral making skills
 Group counseling skills
 Personal integrity
 Consulting skills
 Insight into client’s problems
 Ability to relate to co-workers
 Ability to be objective on the job
 Ethical conduct
 Concern for welfare of clients
 Sense of responsibility
 Recognition of own limits
 Supervisory abilities
 Ability to keep material
 confidential


                                                                                                                10
5. Recommendation: I recommend this application for certification as a Certified Associate Counselor
Alcohol and Drug(CAC-AD)
                             Yes                  No

  Additional Comments:




6. The above information is based upon my best judgment. I am willing to answer additional questions
concerning this evaluation if the Board deems it necessary.



______________________________                                           ______________________
Signature of Reference                                                    Date

After completing this form, please enclose it in a sealed envelope, sign the sealed flap and return it to this
applicant.




                                                                                                          11
                    Maryland Board of Professional Counselors and Therapist
                               4201 Patterson Avenue, Suite 316
                         Baltimore, MD 21215 – 410-764-4740 or 4732
                                  www.dhmh.state.md.us/bopc


                                   ALCOHOL AND DRUG
                              SUPERVISION VERIFICATION FORM
                                          CAC-AD


I, ________________________________________certify that I supervised

________________________________________ From_____________ to ___________ at
          (Applicant’s Name)

___________________________________ located ____________________________________.
        (Place of Employment)                       (Employment Address)


   Full Time                   Part Time (indicate # of hours) Number of hours:


Did this applicant complete 3 years of supervised experience under your supervision?

   Yes                   No

If No, number of years______________________

Did this applicant complete 2,000 hours of supervised experience under your supervision?

   Yes      No

If No, number of hours______________________

Was the Applicant’s practice satisfactory or better?   Yes      No

Title of Applicant’s position________________________________________________

Applicant’s job duties ___________________________________________________________________




                                                                                           12
                                    Detailed Information of Job Duties
Please place a check mark in the box and indicate the number of hours this applicant performed one or
more of the following duties under your supervision:

      Group Counseling                          _______       hrs
      Individual Counseling                     _______       hrs
      Family Counseling                         _______       hrs
      Screening                                 _______       hrs
      Intake                                    _______       hrs
      Orientation                               _______       hrs
      Case Management                           _______       hrs
      Crisis Intervention                       _______       hrs
      Education & Prevention                    _______       hrs
      Referral                                  _______       hrs
      Consultation                              _______       hrs
      Reports and Record Keeping                _______       hrs
      Assess and diagnosis (Diagnostic impression) _______    hrs
      Treatment Planning                           _______    hrs
       Meeting with supervisor                     _______    hrs


    Total Hours ___________ out of 2000 hours




I certify that I am an approved alcohol and drug supervisor as specified in COMAR 10.58.07.02(2). I
further certify that I provided the supervision described above, and that it’s a true and accurate
representation of this supervisor.


 ____________________________________________                  ___________________________________
  Supervisor’s Signature              Date                          License/Certificate Expiration

 _____________________________________                        ___________________________________
  Supervisors Phone number                                          Email Address




                                                                                                      13
                            PLEASE READ

    Fill out the course description form and return it with your application.

    Descriptions of the courses ARE INCLUDED.

    If the titles of your course(s) are different from those in the
     application, include course descriptions, or college syllabi.

    Underline or highlight the courses on your transcript.

    Continuing education is not acceptable for certification. Do not list
     continuing education hours.

Note: The Board makes every effort to conduct a timely review of
applications. However, due to the volume of applications received, it takes
approximately 60 days for the board to render a decision. The licensure
unit will immediately contact you in writing concerning your eligibility.




                                                                             14
         COURSE DESCRIPTION FORM FOR ALCOHOL AND DRUG COUNSELORS # CAC-AD
                    Maryland Board of Professional Counselors and Therapists
                         4201 Patterson Avenue, Baltimore, MD 21215
                                410-764-4732 or 410-764-4740
                                 www.dhmh.state.md.us/bopc/

 Name:
                                Address                                                  State            Zip Code


I am applying for:       CAC-AD
Requirements:        - 21 credits from the list below and 1-credit hour of ethics of alcohol and drug counseling. ALL
COURSES must be from an accredited college. YOU MAY NOT USE CONTINUING EDUCATION
WORKSHOPS TOWARDS CERTIFICATION. Do not list CE hours. Submit your transcript(s) to verify courses.
Include course descriptions or college syllabi where your course titles are different from those listed below. With the
exception of Ethics, you must have at least 3 credits (or 5 quarter credits) in each core area. A course
applied to one core area cannot be used again to fulfill another core area.

 Required Courses 3 credits               Write in Course        Credits   College/University      Date       Grade
 must be in each core area                number(s) & Course     Earned
  below 1-credit in Ethics                title(s). Must be on
                                          transcript.
 (a) Pharmacology of Psychoactive
 drugs
 (b) Individual Counseling
 Techniques

 (c) Group Therapy Techniques
 (d) Abnormal Psychology
 (e) Addictions Treatment
 Delivery
 (f) Topics in Alcohol & Drug
 dependency
 (g) Theories of Counseling &
 Psychotherapy

 (h) Family Counseling

 (i)Human Growth Development

 (j) Ethics with the focus on A&D
 (At least 1 credit required)


Total credits earned:




                                                                                                                     15
          Maryland Board of Professional Counselors and Therapists
               4201 Patterson Avenue, Baltimore, MD 21215
                      410-764-4732 or 410-764-4740
                                       www.dhmh.state.md.us/bopc/


REQUIRED AREAS OF COURSE WORK FOR CERTIFIED ALCOHOL
                        AND
                  DRUG COUNSELORS

A. PHARMACOLOGY OF PSYCHOACTIVE DRUGS -3 credits required
   Instruction in this area shall include all of the following content:

 1. Brain structure and function as it relates to psychoactive drugs.
 2. Classes of psychoactive drugs, including their addition potential, withdrawal symptoms, and associated
    medical problems.

  Examples of courses in this area:

  1. Introduction of Psychopharmacology
  2. Pharmacological Aspects of Additions

B. INDIVIDUAL COUNSELING TECHNIQUES -3credits required

     Instruction in this area shall include all of the following content:

  1. The formation of therapeutic relationship
  2. Therapeutic communication skills

  Examples of courses in this area:
  1. Counseling Methods
  2. Techniques of Counseling

C. GROUP THERAPY TECHNIQUES -3credits required
   Instruction in this area shall include all of the following content:
  1. Therapeutic factors in groups
  2. Stages of development
  3. Types of therapy groups

   Examples of courses in this area:
   1. Group Counseling(or Therapy)
   2. Group Therapy and Practice




                                                                                                      16
D. ABNORMAL PSYCHOLOGY -3 credits required

   Instruction in this area shall include all of the following content:
    1. Major categories of mental disorders
    2. Theoretical models of mental disorders

   Examples of courses in this area:
   1. Abnormal Psychology
   2. Psychopathology

E. ADDICTIONS TREATMENT DELIVERY -3 credits required

    Instruction in this area shall include all of the following content
      1. Screening
      2. Intake
      3. Orientation
      4. Case Management
      5. Crisis intervention
      6. Education and prevention
      7. Referral
      8. Consultation
      9. Reports and record keeping
      10. Assessment and diagnosis based on standard criteria
      11. Treatment planning

       Examples of courses in this area:
       1. Substance Abuse Counseling
       2. Addiction Counseling Theories and Approaches

F. TOPICS IN ALCOHOL AND DRUG DEPENDENCY -3 credits required
    Instruction in this area shall include all of the following content
     1. Various theories in this area shall include all of the following contents:
     2. Models of treatment
     3. Other topics related to alcohol and drug dependency.

      Examples of courses in this area:
          1. Alcoholism and other Drug Dependency
          2. Issues in Theories and Treatment of Alcoholism and Other Drug Dependence

G. FAMILY COUNSELING -3 credits required
   Instruction in this area shall include all of the following content

        1. Family systems theory and dynamics
        2. Family process in addiction.
        3. Family recovery models
      Examples of courses in this area:
       1. Marriage and Family Counseling(or Therapy)
       2. Family Systems and Intervention

                                                                                        17
H. THEORIES OF COUNSELING AND PSYCHOTHERAPY -3 credits required
   Instruction in this area shall include all of the following content

       1. Major theoretical schools and theorists
        Examples of courses in this area:

            1. Theories of Counseling (or Psychotherapy)
            2. Introduction of psychotherapy theories

I. HUMAN GROWTH AND DEVELOPMENT -3 credits required
   Instruction in this area shall include all of the following content
       1. Developmental stages
       2. Expected milestones

    Examples of courses in this area :
          1. Human Growth and Development
          2. Personality Development
J. ETHICS IN ALCOHOL AND DRUG
 Instruction in this area should cover the following:
   1. Self disclosure of recovering counselors
   2. Ethics of being a two- hatter
   3. Self help fellowship participation
   4. Avoiding Dual Relationships
   5. Relapsing Counselor
   6. Confidentiality laws




                                                                         18
         IMPORTANT NOTICE REGARDING
            ICRC-AODA EXAMINATION


                         PLEASE READ
TO BE ELIGIBLE TO TAKE THE ICRC EXAMINATION FOR
CERTIFICATION AS A CSC-AD OR CAC-AD, YOU MUST MEET
THE EDUCATION AND SUPERVISION REQUIREMENTS FOR
CERTIFICATION.

As of April 1, 2011, IC&RC exam changed to Computer Based Testing rather than paper and
pencil. Computer-based testing will be the only means of testing for the credentials (CSC-AD:
Certified Supervised Counselor Alcohol and Drug and CAC-AD: Certified Associate Counselor
Alcohol and Drug) offered by the Maryland Board of Professional Counselors and Therapists.

IC&RC offers three locations in Maryland: Bel Air, Columbia and Annapolis; two in Delaware:
Dover and Georgetown and three in Virginia: Leesburg, Reston and Arlington. Additional sites
will be added in the future.

     APPLICANTS MUST APPLY FOR CERTIFICATION AND RECEIVE BOARD
     APPROVAL BEFORE THEY ARE ALLOWED TO TAKE THE ICRC EXAM.




                                                                                          19

				
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