Certified Co-Occurring Disorders Professional Application

Transcription

1 Certified Co-Occurring Disorders Professional Application A Project of Alcoholism & Substance Abuse Providers of New York State, Inc. 198 Columbia South Turnpike Place, Suite Road, 400, Wallingford, CT Albany New York Phone: info@ctcertboard.org Fax: info@ctcertboard.org

2 CCB Definition of a CCDP CERTIFIED CO-OCCURRING DISORDERS PROFESSIONAL The Connecticut Certification Board defines a CCDP - Certified Co-Occurring Disorders Professional as a person who, by virtue of special knowledge, training, and experience, is uniquely able to inform, motivate, guide, and assist persons with co-occurring addictive and mental health disorders and the unique problems related to these disorders. For the purpose of certification, a Certified Co-Occurring Disorders Professional is defined as a clinician who has demonstrated competence in performing a range of clinical activities and interventions as defined in the Job Task Analysis for Co-Occurring Disorders (2008) by the IC&RC - International Certification & Reciprocity Consortium ( In order to become certified as a CCDP a candidate must demonstrate they have completed appropriate education, training, and supervised experience relevant to the treatment of co-occurring disorders. A qualified clinician is considered to be performing as a co-occurring disorders counselor when: a. the clinician has primary responsibility for providing individual and group counseling interventions specifically related to co-occurring disorders b. the co-occurring specific interventions are identified on a written recovery/treatment plan prepared and reviewed by the clinician in collaboration with the person receiving services c. the interventions are directed toward promoting recovery from co-occurring disorders Although a substantial portion of the clinician's work experience must be in the counseling domain, work experience must involve experience with all of the performance domains in order to be considered appropriate to meet the certification work requirement. Additionally, it is recommended that all functions must be conducted under appropriate clinical supervision CCDP, CCS or SCCS. In all activities, the clinician must demonstrate consistent adherence to the CCB Code of Ethical Conduct (2012) & CCB Code of Ethical Conduct Disciplinary Procedures (2012) and agree to continue their professional development with ongoing education, training and clinical supervision. Once you have submitted your application materials you will receive written confirmation your packet has been received. After your application has been reviewed, we will notify you in writing (via ) within approximately four weeks of the deadline about the status of your application. If changes or additional information are required, you will be notified in writing at that time. We will also notify you, by , when your application has been accepted and you will be invited to sit for the standardized exam. If you have questions about your certification packet after submitting it to us for review, or if you have not received an electronic notification after 4 weeks, please info@ctcertboard.org for assistance. We will attempt to respond to your inquiry as soon as possible. PLEASE DO NOT CALL THE CCB OFFICE TO INQUIRE ABOUT THE STATUS OF YOUR APPLICATION. If you have questions about the certification process, please info@ctcertboard.org for assistance. Step 1 Submit application Submit all documents Pay filing fee Step 2 CCB Staff review of file CCB Board Members review your application Step 3 Upon approval, you are invited to take the exam. Register for exam and pay fee Step 4 Upon passing exam, credential is issued CCDP is issued and effective the following month. Connecticut Certification Board, Inc. CCDP Application July 2016

3 Do not write above line Certified Co-Occurring Disorders Professional Application Form Submission deadline: ongoing Type of Application: CCDP Certified Co-Occurring Disorders Professional Standard (IC&RC Reciprocal) Full Name: Candidate s Candidate s Phone Number: CCB Registry Number: Effective Sept 1, 2010, all candidates must complete a CCB Registry Application prior to applying for any CCB credential. CCDP Fees (All CCB Fees are Non-Refundable) Initial Certification Fees for CCDP Certified Co-Occurring Disorders Professional Application Filing Fee $ IC&RC COD Computer-based Exam $ Renewal Fees for CCDP Certified Co-Occurring Disorders Professional CCDP Annual Renewal Fee $60.00 $55.00 with active CAC CCDP Two Year Renewal Fee $ $ with active CAC CCDP Three Year Renewal Fee $ $ with active CAC CCB Fee Policy: By signing below, I acknowledge the current fees associated with the CCDP credential (listed above) and understand that all fees are non-refundable and may change at any time (for a complete list of CCB fees, please visit the CCB website). I understand that I am responsible for all fees associated with the certification process at the time of my initial application. All fees must be paid by check, credit card (see CCB website) or money order. No cash payments will be accepted. A returned check fee will be due ($35.00) for all returned checks and a hold will be placed on my application until the original and return check fees are received by the CCB. A late fee of $100 will be charged for all CCS renewal applications not received within 30 days of the due date. Candidate s Signature: Date: Connecticut Certification Board, Inc. CCDP Application 1 July 2016

4 Requirements for the CCDP Certified Co-Occurring Disorders Professional Minimum Standards IC&RC Reciprocal credential Initial certification is issued for two-years College Degree A minimum of a Bachelor s degree (CCDP) in co-occurring disorders (COD) or behavioral science with a clinical application from a college or university that is accredited by the U.S. Department of Education or the Council on Higher Education Accreditation or an international equivalent if degree is from an international institution. Supervised Work Experience (Co-Occurring-specific) Training and Education Requirements 6,000 (Bachelor s) or 4000 (Master s) hours specific to co-occurring disorders treatment within the last ten years 140 total hours (Master s) or 200 total hours (Bachelor s): 140 Co-Occurring Disorders specific (with identified domain requirements) 30 -specific (Bachelor s Only) 30 Mental Health-specific (Bachelor s Only) Distance Learning Supervised Practicum Professional References Sent directly to the CCB Exam (IC&RC COD Exam) Up to 150 hours of CCB-approved distance learning can be applied Up to 50 hours of distance learning can be applied if not CCB-approved 200 hours with no less than 20 hours in each of the 7 IC&RC CCDP performance domains 1 positive professional reference from current or most recent clinical supervisor Passing score on the IC&RC COD exam Annual Recertification Standards Must be completed per year to maintain credential 20 hours of co-occurring-specific training Performance Domains CCDP (Bachelor s or Master s Degree Req d) Minimum Training Hours Screening & Assessment 24 Crisis Prevention & Management 18 Treatment & Recovery Planning 24 Counseling & Interventions 24 Recovery Supports & Coordination of Care 18 Psychopathology & Etiology 12 Psychopharmacology 12 CCB Approved Ethics 8 Minimum Specific Training Hours (Bachelor s Only) 30 Minimum Mental Health Training Hours (Bachelor s Only) 30 Minimum Training Hours TOTAL 200 (CCDP)/140 (CCDP-D) I have read the above Standards and understand that I must meet ALL CURRENT STANDARDS in order to become certified as a CCDP. Candidate s Signature: Date: Connecticut Certification Board, Inc. CCDP Application 2 July 2016

5 CCDP Application Submission Requirements Please make sure you complete all of the following items in order to ensure timely processing of your application. Your application will not be processed until you submit the filing fees and all of the following items have been met: Live or work in Connecticut full-time in order to apply for CCDP certification Have a Bachelor s or Master s Degree in COD or a related field Enclose the application filing fee of $ (check or money order payable to CCB) OR Pay online at Date of online payment: Request copies of your academic transcripts be sent directly to the CCB Complete the entire CCDP Application; submit, fill-out, sign, and submit all pages of this packet Work Experience and Supervised Practicum Form (s) completed Request one reference form be completed by your current or most recent clinical supervisor returned to the CCB using the form provided Read and sign Declarations and Authorizations page Initial pages of the CCB Code of Ethical Conduct Submit a CCDP Training Documentation Form which lists all education and training events you wish to apply towards the CCDP that includes at minimum all the following information: Training Date, Title of Training Event and Location of Event Trainer/instructor and Host Organization Length of event (i.e., 6 hours, etc.) Type of event: addiction-specific or elective with addiction content To download the training documentation form, visit the CCB website Attach a copy of certificates of attendance or transcripts for all training/educational events included on the CCDP Training Documentation Form Make a copy of the entire packet for your records prior to submitting to the CCB I have completed all of the above items and submitted them according to the CCB submission requirements and current CCDP standards. Candidate s Signature: Date: Connecticut Certification Board, Inc. CCDP Application 3 July 2016

6 Authorizations and Declarations I hereby attest that all of the information given is true and complete to the best of my knowledge and belief. I understand that falsification of any portion of this application will result in my being denied certification or revocation of same, upon discovery. I acknowledge the right of CCB, Inc. to verify the information in this application or to seek further information from employers, schools, or persons mentioned within. I hereby authorize the CCB to request and receive all records and/or information in any way relating to my application for a CCB credential. I understand that this includes, but is not limited to, verbal or written contacts with my employer(s), colleagues, academic and training institutions, and/or other persons or organizations having pertinent information related to the review of my application. This is a waiver of my privilege that may otherwise exist in respect to the disclosure of such information. I understand that this authorization will expire one year after certification lapses or when my certification expires, once CCB is notified of my intent not to recertify. I further understand that the status of any CCB credential is public record and may be shared by CCB and is available on the CCB website, including effective date, expiration date and certification type. I further understand that if my CCB credential is sanctioned in any way including revocation or suspension that this information is public. I have read, understand, and agree to act in accordance with the Connecticut Certification Board s (CCB) Code of Ethical Conduct (2010) and the CCB s Code of Ethical Conduct Disciplinary Procedures (2010) available on the CCB s website at I will hold CCB, Inc., its Board members, officers, agents, and staff free from any civil liability for damages or complaints by reason of any action that is within their scope and arising out of the performance of their duties which they, or any of them, may take in connection with any examination, and/or failure of the Board to bestow upon me certification with the CCB, the IC&RC, CT Department of Public Health or any other entity. I understand that upon acceptance of my application, additional fees may be due and payable including exam fees, renewal fees, etc. and that all CCB fees are non-refundable without exception. Print Name: Date: Signature: 4

7 CAC Work Experience and Practical Training/Supervision MAKE MULTIPLE COPIES OF THIS PAGE AS NEEDED. USE ONE PAGE FOR EACH EMPLOYER/AGENCY. Employer: Employer Address: City, State: Supervisor s Name: Date of Hire: Total Number of Hours Worked in This Position: Total Number of Hours Providing COD Specific Individual/Group Counseling: Please attach a job description for this position signed by the supervisor listed above. Candidate s Signature Date State of County of Before me, the undersigned notary public, this day, personally, appeared (Supervisor/Affiant) to me known, who being duly sworn according to the law, deposes the following: I hereby attest that the candidate is providing direct, counseling (individual and/or group) to clients with co-occurring disorders and that the information on this page is, to the best of my knowledge, an accurate representation of work performed. This candidate also has primary responsibility for preparing treatment plans and documenting client progress, and is receiving ongoing clinical supervision by an appropriately credentialed professional. Additionally, I attest that the candidate has received at least 200 hours of supervised practical/on the job training in IC&RC s 7 performance domains of cooccurring counseling (published in the Candidate Guide) with a minimum of 10 hours in each of these 7 domains. SUPERVISOR S SIGNATURE: Subscribed and sworn to me this day of, 20 CREDENTIAL(S) My Commission Expires: (Notary Public) Connecticut Certification Board, Inc. CCDP Application July 2016

8 To the CCDP Candidate's Clinical Supervisor: Candidates for CCDP Certified Co-Occurring Disorders Professional are required to submit a satisfactory reference, from the candidate's current or most recent Clinical Supervisor. You are asked as the Clinical Supervisor of the candidate whose name appears on the attached form to complete the attached reference and return to the candidate. Please do not fax or use photocopies as your original signature is required. The reference is an integral part of the certification process. It is therefore imperative that each reference be filled out as completely as possible and returned on a timely basis. CCDP - Certified Co-Occurring Disorders Professional as a person who, by virtue of special knowledge, training, and experience, is uniquely able to inform, motivate, guide, and assist persons with co-occurring addictive and mental health disorders and the unique problems related to these disorders. For the purpose of certification, a Certified Co-Occurring Disorders Professional is defined as a clinician who has demonstrated competence in performing a range of clinical activities and interventions as defined in the Job Task Analysis for Co-Occurring Disorders (2008) by the IC&RC - International Certification & Reciprocity Consortium. In order to become certified as a CCDP a candidate must demonstrate they have completed appropriate education, training, and supervised experience relevant to the treatment of co-occurring disorders. A qualified clinician is considered to be performing as a co-occurring disorders counselor when the clinician has primary responsibility for providing individual and group counseling interventions specifically related to co-occurring disorders; the co-occurring specific interventions are identified on a written recovery/treatment plan prepared and reviewed by the clinician in collaboration with the person receiving services; the interventions are directed toward promoting recovery from cooccurring disorders. Connecticut Certification Board, Inc. CCDP Application 7 July 2016

9 CCDP/CCDP-D Candidate s Name: CCB Registry #: Name of Evaluator (Clinical Supervisor): Title of Evaluator: Agency of Evaluator: CCDP/CCDP-D Clinical Supervisor Reference Form Credentials: Relation to Candidate: Supervisor Administrator Co-worker Other (Specify) INSTRUCTIONS: Please read the description of the various skills outlined below. Using the six-point (0-5) scale shown below, determine the number which most nearly describes the candidate's ability in each category and enter this number in the blank provided to the right of the statement in the column marked "Score". If you have no basis for evaluating the candidate in a particular area, please enter "0" in the scoring column. No basis for judgment Inadequate Needs improvement Competent Above Average Exceptional CCDP Domains Demonstrates a respect for persons with co-occurring substance use and mental disorders. Demonstrates a knowledge of mental illness and substance use etiology and course of illness. Demonstrates an understanding of the pharmacological aspects of mental health treatment and substance use disorders Demonstrates a working understanding of the factors that determine a client s appropriateness and eligibility for various treatment modalities. Demonstrates the ability to explain the nature, goals and rules of the program to the client in a manner which develops rapport and reduces client anxiety. Demonstrates the ability to assess the impact of the co-morbidity of mental health and substance use disorders. Demonstrates the ability to design, implement and ensure a highly individualized recovery plan of action. Demonstrates interventions and support strategies, program models, and philosophies. Demonstrates the ability to access, coordinate, and facilitate community, peer, and natural support systems to maximize treatment and recovery opportunities. Demonstrates the ability to teach both simple and complex skills and information to clients with co-existing mental health and substance use disorders. Demonstrates a practical knowledge of a range of crisis prevention, intervention and resolution approaches. Demonstrates the knowledge and skills necessary to assess and respond to meet the needs of the client which cannot be met by the treatment program. Demonstrates the skills to appropriately document all information necessary to meet legal requirements and to facilitate the effective treatment. Demonstrates an awareness for the need for ongoing consultation and clinical supervision to facilitate the appropriate treatment of the client. Demonstrates a working knowledge of ethical principles, individual clients civil rights, and the law. Demonstrates a multi dimensional understanding of the needs and concerns of special populations, including the physically challenged, hearing impaired, geriatric and HIV populations, as well as concerns regarding the additional complexity of culture, gender, sexual orientation, race, ethnicity, and religious beliefs. Demonstrates a working knowledge of medical, cognitive and functional impairment concerns and how these concerns impact people with co-occurring disorders. Demonstrates a working knowledge of forensic and legal concerns including involvement with PSRB, probation, parole, DCF, the court and mandated treatment, and how these concerns impact co-occurring disorders treatment. Score Name of Rater: Date: Rater s Signature: Credentials: Please note: Clinical Supervisor is preferred to be credentialed as a CCS (Certified Clinical Supervisor) or CCDP-D (Certified Co-Occurring Disorders Professional-Diplomate) but not required. Connecticut Certification Board, Inc. CCDP Application 8 July 2016

10 CCDP Candidate's Name: CCB Registry #: CCDP Training Documentation Form Please number each copy of training verification (certificate or transcript) to correspond with the line number listed on this form Please attach to this form verification (copy of a certificate of attendance or transcript) for all trainings listed on this form. # Training Date Course/Training Title Training location and Sponsor EXAMPLE Instructor Contact hours Documentation type Specific 1 Fall 2009 Intro to Psychology Tunxis CC/DARC Freud 45 Transcript No YES 2 April/22/2009 Ethics in Behavioral Health Mountainside Quamme 3 Certificate YES YES Elective with Content

11 CCDP Candidate's Name: CCB Registry #: CCDP Training Documentation Form Please number each copy of training verification (certificate or transcript) to correspond with the line number listed on this form Please attach to this form verification (copy of a certificate of attendance or transcript) for all trainings listed on this form. # Training Date Course/Training Title Training location and Sponsor EXAMPLE Instructor Contact hours Documentation type Specific 1 Fall 2009 Intro to Psychology Tunxis CC/DARC Freud 45 Transcript No YES 2 April/22/2009 Ethics in Behavioral Health Mountainside Quamme 3 Certificate YES YES Elective with Content

12 CCDP Candidate's Name: CCB Registry #: CCDP Training Documentation Form Please number each copy of training verification (certificate or transcript) to correspond with the line number listed on this form Please attach to this form verification (copy of a certificate of attendance or transcript) for all trainings listed on this form. # Training Date Course/Training Title Training location and Sponsor EXAMPLE Instructor Contact hours Documentation type Specific 1 Fall 2009 Intro to Psychology Tunxis CC/DARC Freud 45 Transcript No YES 2 April/22/2009 Ethics in Behavioral Health Mountainside Quamme 3 Certificate YES YES Elective with Content

13 CCDP Candidate's Name: CCB Registry #: CCDP Training Documentation Form Please number each copy of training verification (certificate or transcript) to correspond with the line number listed on this form Please attach to this form verification (copy of a certificate of attendance or transcript) for all trainings listed on this form. # Training Date Course/Training Title Training location and Sponsor EXAMPLE Instructor Contact hours Documentation type Specific 1 Fall 2009 Intro to Psychology Tunxis CC/DARC Freud 45 Transcript No YES 2 April/22/2009 Ethics in Behavioral Health Mountainside Quamme 3 Certificate YES YES Elective with Content

14 CCDP Candidate's Name: CCB Registry #: CCDP Training Documentation Form Please number each copy of training verification (certificate or transcript) to correspond with the line number listed on this form Please attach to this form verification (copy of a certificate of attendance or transcript) for all trainings listed on this form. # Training Date Course/Training Title Training location and Sponsor EXAMPLE Instructor Contact hours Documentation type Specific 1 Fall 2009 Intro to Psychology Tunxis CC/DARC Freud 45 Transcript No YES 2 April/22/2009 Ethics in Behavioral Health Mountainside Quamme 3 Certificate YES YES Elective with Content

15 Important Information about Your CCDP Application Submission Requirements All forms submitted must be original and signed without any alterations or modifications. Any forms with white-out, scribble marks or changes will be denied. If a change is required, please complete a new form. No photocopies or faxed forms will be accepted. Please do not fax any materials to the CCB related to a certification application. The work experience/practicum form must be notarized prior to submission.. Verification of a college degree or college course work If you are interested in utilizing a college degree as part of the certification process, you must submit your official transcript. The transcript must be mailed directly from the accredited educational institution to the CCB. Only relevant degrees qualify, and only transcripts from institutions accredited by the US Department of Education apply. In order to document college course work, you must submit your official transcript that shows the course has been completed (with a grade of C minus or better). Only transcripts from institutions accredited by the US Department of Education apply. Training Documentation When documenting training and education for the CCDP credential, you must submit a CCDP Training Documentation Form (you can download a copy from the CCB website) with all required information completed. Please attach a copy of all certificates of attendance or transcripts for all training/educational events listed on the form. Attached to the form, you must include a copy of all certificates of attendance or transcripts for all training/educational events included on the CCDP Training Documentation Form with each certificate or transcript numbered according to the CCDP Training Documentation Form. Credential Requirement for Certification Documentation by Professionals All credentials are verified to ensure the credential(s) of professional documenting requirements for certification are active at the time of submission. Application Review Process You must pay the filing fee and submit all required application materials before your application is reviewed. Incomplete applications will not be reviewed. The CCB is an independent, nongovernmental, 501(c) 3 nonprofit organization that offers certification for addiction counselors, clinical supervisors, cooccurring disorders and prevention professionals in Connecticut. The Board has established specialty certificates in substance abuse, co-occurring disorders, and problem gambling for professionals licensed and credentialed in other behavioral healthcare domains. The Board is active in a number of important state-wide workforce development initiatives, provides training/ continuing education and ensures that the trainings provided in Connecticut by approved vendors meet established standards. What are the Benefits of Certification? Certification identifies professionals who are specialists in their field. Certified professionals are recognized by professional affiliations, state, and national legislation. Certified professionals are provided with the opportunity for peer networking, in addition to involvement and impact through CCB sponsored education opportunities and committee work. Certification increases professionalism in the field. Certification provides a strong basis for employment hiring and professional advancement. Certification provides the certified professional freedom to move to another state within the International Certification and Reciprocity Consortium Member Boards and be granted that state's credential via the process of reciprocity. Who Benefits from Certification? The Patient / Client Certification assures competent, professional services while continuously improving the quality of service being provided to the client and family members. The Public Certification promotes standards of training and competency that will meet standards required for licensing, accreditation, and third-party payers. The Certified Professional Certification provides recognition of competency and a marketable credential that will enhance the role of the professional. The Profession Certification provides opportunity whereby the highest professional standards can be established, maintained, and updated.

16 To protect the public by enhancing recovery-oriented workforce capacity Strengthen health and human services performance and outcomes by enhancing the recovery-oriented skills and capacity of the workforce If you have questions or need assistance with your application please contact Jeff at The Connecticut Certification Board, Inc. offers the following Certifications: Certified Counseling Counselor in Training Clinical Supervision Co-Occurring Disorders Medication Treatment Certified Peer Specialist Prevention Gambling Criminal Justice The CCB Science 2 Service Distance Learning Program is a selfpaced learning program that was developed using science-based materials within the public domain such as TIPs -Treatment Improvement Protocols (SAMHSA/CSAT), TAPs Technical Assistance Publications (SAMHSA/CSAT), research reports and training manuals. This program allows participants to earn CCB approved training hours that can be applied toward initial certification or renewal while reading high quality science-based content. The featured documents are widely available within the public domain, free of charge and in many cases participants may already be familiar with the content. The purpose of the program is to provide participants with an introduction to the content in a structured manner while providing technical assistance and verification of learning through the use of pre and post-tests Connecticut Certification Board, Inc. 100 South Turnpike Road, Wallingford, CT info@ctcertboard.org (203) Fax: (203)