Michigan Registration/Development Plan for Clinical Supervisors

Michigan Registration/Development Plan for
Clinical Supervisors

Authority

Individuals providing clinical supervisory 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 and the Treatment Agency

The Development Plan will also serve as a method by which statewide data will be collected regarding professional clinical supervisors. The data is important in identifying the ongoing status of the substance abuse 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 Development Plan:

General Information

The Registration/Development Plan is required for all individuals, not currently certified with MCBAP, providing clinical supervisory 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.

The Clinical Supervisor Code of Ethics must be read prior to signing the Development Plan Assurances.

Submit a $50.00 non-refundable processing fee.

The Development Plan cannot be renewed.

Demographic Information

This section contains questions for the purpose of providing valuable information that allows current trends in the treatment profession in the State of Michigan.

Aggregate data will only 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 address, 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 Clinical Supervisors

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 substance abuse

Hours of college education training specific to substance abuse

Hours of training specific to clinical supervision

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	NAC-I (NAADAC)
CPC-M	RN	NACA-II (NAADAC)
CPC-R	CHES	MAC (NAADAC)
CPS-M	LBSW	NBCC
CPS-R	LMSW	CEAP
CCJP	LPC	APA Addiction specific
LP	RSST	Other (specify)
LLP	NASW ATOD specialty

Work Status

Salaried

Contractual

Volunteer

How long (years, months, etc.) have you worked in the substance abuse treatment/prevention field?

How long have you worked as a clinical supervisor

Typical hours worked per week in substance abuse treatment or 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

Residential

Detoxification

Intensive Outpatient

Outpatient

Methadone

Supervision/Management/Administration

Primary role/responsibility function

Primary Therapist

Case Management

Clinical Supervisor

AAR screener/assessor

Medical/Psychiatric

Administrator

Residential aid/milieu technician

House manager/attendant

Didactics

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 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 four (4) years to become certified.

Four (4) Year Plan

Predictions: Clinical Supervision Education and Experience over the next 4 years

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

Hours of education training specific to clinical supervision (10 hours minimum, per year)

Hours of work experience in a substance abuse treatment setting providing clinical supervision

Applicant

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

I acknowledge I have received, read and understand the Clinical Supervisor's Code of Ethics and do agree to its terms.

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

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

I understand that my Development Plan cannot be renewed.

I understand that if I am pursuing the MCBAP Clinical Supervision Certification; all requirements needed to obtain certification will be met, and I must be certified by the time of expiration in four (4) years.

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.

	Applicant's Date of Hire
	Applicant’s name (type or print clearly)
	Applicant's Signature
	Date

Agency Director/Administrator

I affirm this treatment agency’s responsibility and commitment to assist the above named applicant of this Clinical Supervisor Certification Development Plan in gaining the necessary education, training and experience required for certification as a clinical supervisor. This will include but may not be limited to the Certified Clinical Supervisor Performance Domains.

I affirm that the above-identified Clinical Supervisor has been assigned or is contracted to provide the clinical supervision responsibilities for our Agency.
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:
City/Township:
County:
State:
Zip:
Telephone:
Fax:
Email Address:

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