Michigan Certification Board for Addiction Professionals

3474 Alaiedon Parkway, Suite 500, Okemos MI 48864

Application For Renewal of Registration/Development Plan for Addiction Counselors


Please complete this document and do not submit any additional documentation at this time.

NOTE: You can apply for certification at any time during your 24 month Development Plan.



SECTION I: Demographics (Please Print)
 
Name                                                               Social Security Number (last 4 digits)                                  

Address_________________________________ 

County _______________________

City __________________________

State __________ 

Home Phone   (_____)_________________ 

Daytime Phone  (_____)_________________ 

Email Address_________________________________ 

Zip Code ______________




SECTION II: Renewal Fees

Remit a non-refundable renewal fee of $25.00 for a 2 (two) year plan period.




SECTION III: Assurances

Previous Year: Substance Abuse Education and Experience over the past 12 Months

______Hours of education training specific to substance abuse

______Hours of supervised clinical work experience in a substance abuse treatment setting

______Hours of supervised practical training

 

SECTION IV: Signature statement

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

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

III. I understand that I must meet all the certification requirements, including: Experience, Education, Supervision, and Testing, and be certified by the expiration date of my development plan.

IV. I understand that this is a two-year plan and is not renewable after the two years.

Applicant's Name (type or print clearly)                                                                       

Applicant's Signature                                                                          

 Date                                        

 

SECTION V: Clinical Supervisor

As the Clinical Supervisor, I attest to the following:

I. I agree to provide the applicant with supervised counseling experience and training in the Global Criteria contained within the Twelve Core Counselor Functions as identified by MCBAP and IC&RC/AODA, Inc.

II. I understand that I may be held ethically responsible for the treatment provided by the supervisee.

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

IV. I understand this Development Plan is not renewable.

V. I understand that the applicant must be certified by the expiration date of their Development Plan.

Clinical Supervisor's Name (type or print clearly)                                                                            

Supervisor's Signature and Credentials                                                                                           

 Date                                                


SECTION VI: Agency Director/Administrator

As the Agency Director, I attest to the following:

I. I affirm this treatment 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 substance abuse counselor. This will include but may not be limited to the Global Criteria contained within the Twelve Core Counselor Functions.

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

III. I understand this Development Plan is not renewable.

IV. I understand that the applicant must be certified by the expiration date of their Development Plan.




Agency Name                                                                                             

Treatment Agency Director/Administrator's Name                                                                                               

Treatment Agency Director/Administrator's Signature                                                                                             

Date                                                 

 Feb 01/2008