Michigan Registration/Development Plan for 
ATOD Prevention Specialist

 Authority

Individuals providing ATOD prevention services in Office of Drug Control Policy (ODCP) funded programs contracted with Regional Coordinating Agencies are required to be certified with the Michigan Certification Board for Addiction Professionals (MCBAP). If the registrant currently does not meet the qualifications to be certified he or she must complete and submit a Development Plan to show they are making reasonable progress toward becoming certified with MCBAP.


Application to Practice 

The Developmental Plan is intended to assist in identifying the steps you must take to meet contractual requirements in the State of Michigan.

 Objective

The Registration/Development Plan contract is an effort to assure the public of the State of Michigan, that the registrant will be provided the conditions and support to make reasonable progress toward becoming certified with the Michigan Certification Board for Addiction Professionals (MCBAP). The Development Plan on file with MCBAP brings about an added layer of protection to the clients served by the agency and public at large. The plan also provides accountability to the Registrant, Clinical Supervisor and the Treatment Agency

The Development Plan will also serve as a method by which statewide data will be collected regarding professional ATOD prevention specialist. The data is important in identifying the ongoing status of the prevention workforce in the State of Michigan. The information will assist with identification of future needs, e.g., competency standards, credentialing, training, education, future funding and other planning activities. The aggregate data will be shared with groups such as providers, Regional Coordinating Agencies, Office of Drug Control Policy (ODCP), elected officials and other interested parties.

 Professional Development Process
The Development Plan is intended to identify steps required to seek MCBAP certification.

For more information regarding requirements for certification in the State of Michigan, refer to the “Requirements” section of the MCBAP website or contact the MCBAP office at 517-347-0891.                             

Directions for completing the registration form:

 General Information

  • The Registration/Development Plan is required for all individuals, not currently certified with MCBAP, providing ATOD prevention services in ODCP funded programs contracted with Regional Coordinating Agencies.

  • Registration/Development Plans must be completed and submitted to MCBAP within 30 business days of beginning employment.

  • This information must be typed or printed clearly.

  • Agency information should include the official name of all agencies at which you are providing services.

  • Submit a $50.00 non-refundable processing fee.

  • The Development Plan must be renewed annually.

 

Demographic information

  • This section contains questions for the purpose of providing valuable information that allows current trends in the prevention profession in Michigan to be evaluated.

  • Aggregate data only will be disseminated to the State of Michigan and to the Profession.

  • Your individual responses will remain confidential.

Reporting Status Changes: 

  • Notify MCBAP if your name, home or business address, or phone number changes after your Registration/Development plan has been submitted.

  • Submit a revised form if your address or employment has changed. If you change agencies this plan is no longer valid until you update it. The revised form needs to only include new information. An additional fee is not required.

 
 Application for Michigan Registration/Development Plan ATOD Prevention Specialist

General Information (type or print clearly)

Last Name

First Name

 MI

 Home Address

 City

 

 County

 

 State

 Zip

 

 Fax

 Telephone

Social Security # (last 4 digits) 

 Email

 

Gender (optional):     Female      Male

 

 What is your age (optional)?             yrs.

 

Primary Race/Ethnic Group (optional)

  White/Caucasian (non-Hispanic) 

  Asian American

  Black/African American (non-Hispanic)

  Native American/Indian

  Native Hawaiian/Pacific Islander 

  Alaska Native

  Hispanic/Latino

  Arab/Chaldean

  Other (please specify)                                                   

 

Complete the following information regarding your current substance abuse services agency location

 

Agency Name:

Your Title:

Street Address:

City/Township:

County:

State:

Zip:

Agency Email Address:

Telephone:

Fax:


Past Education and Counseling Experience

 I have passed the following exams (check all that apply):

Fundamental of Substance Abuse Counseling (FSAC)

IC&RC Counselor Exam

Fundamentals of Alcohol & Other Drug Problems (FAODP)

IC&RC Prevention Specialist Exam

Effective Counseling with Special Populations (SPEX)

IC&RC Clinical Supervisor Exam

Assessment and Referral Management Specialist (ARMS)

Case Presentation Method (CPM) Oral

Other (specify)                                                        

  

How many hours have you completed in the following areas?

                Hours of education training specific to ATOD prevention

                Hours of college education training specific to prevention

 Education Background

  No High School Diploma 

  High School Diploma or equivalent

  Some College- no degree

  Associates Degree

  Bachelors Degree

  Masters Degree

  Doctoral Degree

  Physician MD/DO

  Physician Assistant 

  Nurse Practitioner

  Other (specify)                                                                 


Certification/Licensure (identify if temporary status)

  ARMS

  LPN

  NACA-I (NAADAC)

  CAC-M

  RN

  NACA-II (NAADAC)

  CAC-R 

 CHES

  MAC (NAADAC)

  CCS

 LBSW

  LPC

  CCJP

  LMSW

  NBCC

  LP

  RSST

  CEAP

  LLP

  NASW ATOD specialty

  APA Addiction specific 
 Other (specify)                                               


     Work Status

      Salaried

      Contractual

      Volunteer

 

 How long have you worked in the prevention field?                         

Typical hours worked per week in prevention work                         

 

 Annual salary from treatment or prevention work   

_____
 
$0 - $10,000     
 
                      _____ 
 
$51,000 - $60,000
 
_____
 
$11,000 - $20,000 
 
                       _____ 
 
$61,000 - $70,000
 
_____ 
 
$21,000 - $30,000  
 
                     _____ 
 
$71,000 - $80,000
 
_____ 
 
$31,000 - $40,000
 
                       _____ 
 
$81,000 - $90,000
 
_____ 
 
$41,000 - $50,000    
 
                      _____ 
 
$91,000 - $100,000


Type of service in which you spend the majority of your time 

  Prevention
  Detoxification
  Parenting groups
  Intensive Outpatient
  Schools
  Methadone
 Community Coalitions
  Supervision/Management/Administration

 

Primary role/responsibility function 

  Specifically focused staff 

  Management

  Supervisor
  Volunteer
  Community organizer

  Administrator
  School counselor
                                                       Other (please list)

 

Assurances 

Prior to submitting this Development Plan to the Michigan Certification Board for Addiction Professionals (MCBAP) for review, all parties to this agreement: the Applicant, the Clinical Supervisor, and the Treatment Agency Director, must fill out and sign and date their respective section of the assurances. All individuals involved understand the applicant has two (2) years to become certified. 

 

 Two (2) Year Plan

 Predictions: ATOD Prevention Education and Experience over the next 2 Years

 During the next two years, how many hours do you plan to acquire in the following areas?

               Hours of education training specific to ATOD prevention (60 hours recommended, annually)

               Hours of supervised work experience in a prevention setting (1,000 hours recommended, annually)

               Hours of supervised practical training (60 hours recommended, annually)

 

Applicant

  1. I certify that I prepared all the enclosed Development Plan application materials and this information is true and correct.

  1. I acknowledge I have received, read and understand the Prevention Code of Ethics and do agree to its terms.

  1. I agree to gain the education, supervision and experience necessary to maintain compliance with my Development Plan.

  1. I understand that if my Development Plan is suspended or revoked as a result of my breaching the Prevention Code of Ethics, I will return my registration certificate to the MCBAP office immediately.

  1. I understand that my Development Plan cannot be renewed.

  1. I understand that if I am pursuing the MCBAP ATOD Prevention Certification; all requirements needed to obtain certification will be met, and I must be certified by the time of expiration in two (2) years.

  1. I hereby authorize MCBAP the release of my name and information in my development plan for review by employers, Regional Coordinating Agencies and other entities vested in my professional development.

  2.  
                                                                  

Applicant's Date of Hire
                                                                                     

Applicant’s name (type or print clearly)
                                                                                         

Applicant's Signature
                                                                  

Date 


 Clinical Supervisor

 As the Clinical Supervisor, I attest to the following:

  1. I agree to provide the applicant with supervised experience and training in the IC&RC/CPS Performance Domains as identified by MCBAP and IC&RC/AODA, Inc.

  1. I understand that I may be held ethically responsible for the services provided by the supervisee.

  1. I agree to meet the supervision responsibilities of this Development Plan.

  2.  I understand the Development Plan is not renewable and the applicant must be certified by the expiration date of the plan.

           Clinical Supervisor’s name (type or print clearly)

                                                                                                      

   Supervisor’s Signature and credentials                                                          Date

 

 Agency Director/Administrator

  1. I affirm this agency’s responsibility and commitment to assist the above named applicant of this Development Plan in gaining the necessary education, training and supervised counseling experience required for certification as a ATOD prevention specialist. This will include but may not be limited to the IC&RC/CPS prevention performance domains.

  1. I affirm that the above-identified Supervisor has been assigned or is contracted to provide the supervision responsibilities for the previously named applicant of the Development Plan.

  1. I understand the Development Plan is not renewable and the applicant must be certified by the expiration date of the plan.

            Agency Name

 Treatment Agency Director/Administrator’s name (type or print clearly)

                   

                                                                                                                                 
     Treatment Agency Director/Administrator’s Signature                               Date


 

TO BE COMPLETED BY THE REGIONAL COORDINATING AGENCY 

Regional Coordinating Agency:

Regional Coordinating Agency Director or Designee:

 Street Address:

 Telephone:

Fax:

 City/Township:

 Email Address:

 County:

State:

Zip:

      

                

For MCBAP office use only:  

Approved      _____ Denied _____

Staff Signature:                        ________________________________                            

    Date:  __________________

 

When completed, mail signed registration/development plan to :       

MCBAP

3474 Alaiedon Parkway, Suite 500

Okemos, MI 48864

(517) 347-0891

(517) 347-1288 FAX

micbap@aol.com

 

         

 

 

Revised 03/2008