Michigan Certification Board for Addiction Professionals

3474 Alaiedon Parkway, Suite 500, Okemos MI 48864

Application For Renewal of Registration/Development Plan for Clinical Supervisors

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 Three Year 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 3 (three) year plan period.



SECTION III: Assurances

Previous Year: Clinical Supervision Education and Experience over the past 12 Months

______Hours of education training specific to Clinical Supervision

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



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 three-year plan and is not renewable.

Applicant's Name (type or print clearly)                                                                                                   

Applicant's Signature                                                                                       

Date                                               

 

SECTION V: 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                                             

Jan 31/2008