CDCS
Application
ChemicalDependencyClinical
Supervisor
Revised January 2015 DIRECTIONS/CHECKLIST
□ Official transcript required sent directly from college/university to the RICB Office. □ Certificates of attendance for trainings. □ All required documentation to support employment (i.e. letters from former employers verifying employment, current job description, signed and dated by applicant and supervisor). □ Sign and date the Code of Ethical Conduct. □ Supervision form completed and signed by supervisor. □ Fee of $250 if applicant holds a current reciprocal credential of ACDP, ACDP II, CCDP, CCDP Diplomate, or CCJP certification. Fee of $350 if applicant does not hold a current reciprocal credential as listed. May be paid by check/money order (payable to RICB) or with PayPal or with VISA, MasterCard or Discover. If paying through PayPal, fee must be paid prior to submission of application. One‐half of fee is refundable if application is denied or cancelled prior to the exam – no refund if application is denied or cancelled after exam. If an employer or organization is covering the cost of your application fee, they must include the applicants name with the payment. Failure to include the applicants name will result in delay in approval of the application. When the application is approved, you will be notified about scheduling the exam. If there are any problems with the application, you will be notified by email. Applications are open for a period of one year after the date of review. If an applicant fails to fulfill all certifications requirements within that year, the application will be closed and no refund will be issued. Keep a photocopy of the entire application. Send your completed application, copies of certificates of attendance, attachments, and fee to: RICB 298 S. Progress Avenue Harrisburg, PA 17109 Phone: 401‐349‐3822 Fax: (717) 540‐4458 Website: www.ribccdp.com Email: info@ribccdp.com RICB 2
REQUIREMENTS FOR CDCS
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Applicant must hold a current and valid reciprocal credential of ACDP, ACDP II, CCJP, CCDP or CCDPD, or have a specialty substance abuse credential in another professional discipline in the human services field at the Master’s level or higher. A CDCS awarded to a professional that does not have a required reciprocal level credential does not qualify for reciprocity. Five years (10,000 hours) of alcohol and drug counseling experience. Two years (4,000 hours) of clinical supervisory experience in the alcohol and drug field. These two years may be included in the five years of substance abuse counseling experience. An Associate’s degree in behavioral science may substitute for 1000 hours; a Bachelor’s degree in behavioral science may substitute for 2000 hours; a Master’s degree in behavioral science may substitute for 4000 hours. Applicant must be employed within one year prior to application in a clinical supervisory position at the time of application to RICB. Acceptable employment is based on a specific aspect of staff development dealing with the clinical skills and competencies for persons providing counseling. The format for supervision is commonly one‐to‐one and/or small groups on a regular basis. Methods for review often include case review and discussion, utilizing direct and indirect observation of a counselor(s) clinical work. Current job description signed and dated by supervisor and applicant. Supervision 
200 hours with a minimum of 10 hours in each domain. Supervision must be face‐to‐face. Education 
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30 hours of didactic education in clinical supervision or a three credit course relevant to the domains including six hours in ethics, with a minimum of four hours in each domain. Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in‐services, college/university credit courses and RICB approved distance learning/online education. There is no limit to the number of distance learning/online education that can be submitted. Education must be specifically related to the knowledge and skills necessary to perform the tasks within the domains. Three college credits are equivalent to 45 hours. Education, as defined above, applicant provides to others may also be used providing it is verified in writing by sponsoring school or agency. Examination 
Pass the IC&RC Examination for Clinical Supervisors. Other 
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Signed and dated Code of Ethical Conduct. Signed, dated and notarized Release. Current job description dated and signed by supervisor and applicant. Reference from current or previous supervisor. Domains 1. Counselor Development 2. Professional & Ethical Standards 3. Program Development & Quality Assurance 4. Performance Evaluation 5. Administration 6. Treatment Knowledge RICB 3
Fees Certification: Retest: Exam Cancellation: $250 – if applicant holds a current ACDP, ACDP II, CCDP, CCDP Diplomate, or CCJP $350 – if applicant does not hold a current ACDP, ACDP II, CCDP, CCDP Diplomate, or CCJP (fee must accompany application and materials) $150 $150 CERTIFICATION TIME PERIOD RICB certification encompasses two calendar years commencing on the date of passing the exam. Two dates, date of issue and valid through, will appear on the certificate along with a certification number. APPEAL PROCESS The purpose of appeal is to determine if RICB accurately, adequately and fairly reviewed applicant's file. A letter requesting an appeal must be made to RICB in writing within 30 days of the notification of the board's action. A person shall be considered notified three days after the relevant date of mailing. The written appeal will be sent to the Executive Committee who in turn will thoroughly review the entire application and materials to determine whether or not applicant should have been denied approval. Applicant will be notified in writing as to the findings of the Executive Committee. EXAMINATION INFORMATION Type: This credential requires successful completion of the IC&RC exam which is offered as an on‐demand computer based exam administered at an approved testing site. Three hours are permitted to complete the 150 question, multiple choice exam. Candidates will be notified by RICB, once application for certification is approved, on how to register for the computer based exam. Dates: The IC&RC exam is offered on‐demand at approved testing centers thereby allowing candidates to test on a date and time convenient for them. Candidates will receive information from RICB on registering for on‐demand testing once application for certification is approved. Content: The IC&RC Job Analysis for this credential identified domains which make up the questions in the exam. Within each domain are several identified tasks that provide the basis for questions in the exam. Candidate Guide: The domains, including the task statements per domain, sample exam questions, and a list of references are included in the free Candidate Guide. Candidate Guides are available from the RICB website. Study Guides: Professional study guides have been published for several of the exams. Study Guides are available for sale from professionals.internationalcredentialing.org. Locations: There are several computer based testing sites in Rhode Island. Candidates can choose the testing site that is closest for their travel. Special Situations: Individuals with disabilities and/or religious obligations that require modifications in exam administration may request specific procedure changes, in writing, to RICB no fewer than 60 days prior to the scheduled exam date. With the written request, candidate must provide official documentation of the disability or religious issue. Contact RICB on what constitutes official documentation. RICB will make arrangements for appropriate modifications to its procedures when documentation supports this need. Cancellation/Rescheduling Policy: Candidates are required to arrive on time for their exam. Candidates who arrive late will not be permitted to test and will be charged a $150.00 cancellation/rescheduling fee. Candidates who cancel or reschedule their exam less than five days prior to their scheduled date will be charged the full testing fee. Candidates who cancel or reschedule more than five days before their scheduled date will be charged a $25.00 cancellation/rescheduling fee. Retest: Candidates failing the exam can retest after a 60 day wait period from date of last taking the exam. Candidates will be sent retest instructions from RICB. RICB 4
LICENSING Applicants who successfully meet all CDCS requirements are eligible for Licensed Chemical Dependency Clinical Supervisor (LCDCS) designation. Candidates must complete the licensing application and submit it directly to the Rhode Island Board of Licensing for Chemical Dependency Professionals (RIBLCDP). Application can be found at: http://www.health.ri.gov/applications/ChemicalDependencyProfessional.pdf. The CDCS is a mandatory prerequisite for the LCDCS. RECERTIFICATION To maintain the high standards of this professional practice and to assure continuing awareness of new knowledge in the field, RICB requires recertification every two years. To be recertified as a CDCS, an individual must: 1. Hold a current and valid certificate issued by RICB; 2. Acquire six hours of RICB approved clinical supervision specific education received within the two year recertification cycle; 3. Verify that you have reviewed, read and will uphold by practice the RICB Code of Ethical Conduct for professional behavior; 4. Complete an application and pay the recertification fee. LAPSED CERTIFICATION The completed recertification application should be received at RICB prior to the expiration date. If the application is incomplete, applicant will be notified by phone or email depending on what has been indicated by applicant. There is no grace period. If the recertification is not completed by the expiration date, the individual will no longer hold a CDCS and no further use of the CDCS is permitted until the individual has recertified. All certified professionals should review the recertification application well in advance of the expiration date. A Reinstatement Fee is due if the recertification is late between one day and one year. After one year, no recertification is possible and applicant would have to reapply for the credential, meeting all current requirements. INTERNATIONAL CERTIFICATION & RECIPROCITY CONSORTIUM (IC&RC) The purpose of the IC&RC is: 
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to promote uniform professional standards and quality assurance for the alcohol and drug profession and to give the profession greater visibility throughout the United States and other countries; to negotiate reciprocity agreements for alcohol and drug professionals with certification bodies throughout the United States and other countries; to provide support services, including consultation and training to all states in all areas of certification, such as establishment of standards, evaluation of competence, establishment and training of boards and committees; to provide information on certification and certification activities throughout the United States and other countries; to provide an International Certificate (ICCS) for clinical supervisors meeting specified qualifications certified by individual IC&RC member certification boards. Addiction Professionals who hold a reciprocal level credential through RICB are automatically eligible for an International Certificate from IC&RC. RICB will add a seal to your certificate indicating the international status of your certification. If you would like to receive an international certificate you can download the necessary form at www.internationalcredentialing.org; to promote uniform professional standards in CCS specialty disciplines. Certified professionals in the state of Rhode Island have reciprocity with many certifying bodies throughout the United States and other countries as well as all of the armed services. For reciprocity process and/or a listing of member boards, please call the RICB Office. RICB 5
APPLICATION FOR CDCS
Please type or print only. Date: Date of Birth: □ Male □ Female
Name: SSN:
Please print your name as it should appear on your certificate Home Address: City: State:
Zip: County: Home Phone: Email:
(required) College/University: Name on Transcript: Employer: Position/Title:
Employer City: Employer Zip: County: Work Phone:
Ext: Dates Employed: Hours per Week: Immediate Supervisor: Title: Phone: Email: I hereby attest that the applicant is working in a position where a minimum of 51% of his/her time is spent providing supervision of counseling. ____________________________________________________ Supervisor’s Signature Why are you pursuing certification? (required) Have you ever received any disciplinary action from another certification or licensing authority? □ Yes □ No If yes, please explain in full on a separate sheet. Have you ever been convicted of a felony violation in any state or federal law? □ Yes □ No If yes, please explain in full on a separate sheet. Have you ever been licensed/certified in any other state? □ Yes □ No If yes, please explain in full on a separate sheet. Fee of $250/$350 can be paid using one of the following: □ Check/MO (payable to RICB) □ PayPal □ Credit Card (Visa, MasterCard or Discover) 3‐digit code: Exp. Date: Billing address: (If different than Home Address) ‐ Name on Card: ‐ ‐ RICB 6
PREVIOUS RELEVANT EMPLOYMENT, IF APPLICABLE Include letter (on company letterhead) from previous employer verifying your duties and dates employed. Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
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SUPERVISION To Supervisor: Please complete this form indicating applicant's on‐the‐job supervision. This form is not intended to document applicant's total number of hours worked but rather the hours of on‐the‐job supervision you have provided the applicant. Supervision is a formal or informal process that is administrative, evaluative, clinical, and supportive. It can be provided by more than one person, it ensures quality of clinical care, and extends over time. Supervision includes observation, mentoring, coaching, evaluating, inspiring, and creating an atmosphere that promotes self‐motivation, learning, and professional development. In all aspects of the supervision process, ethical and diversity issues must be in the forefront. Applicant’s Name: I hereby attest that a minimum of 200 hours of supervision in the domains have been attained by the above‐named applicant. At least 10 hours in each of the domains were received as outlined below. CDCS DOMAINS # OF HOURS RECEIVED IN EACH 1. Counselor Development ________________ 2. Professional & Ethical Standards ________________ 3. Program Development & Quality Assurance ________________ 4. Performance Evaluation ________________ 5. Administration ________________ 6. Treatment Knowledge ________________ TOTAL MUST BE AT LEAST 200 HOURS ________________ ________________________________________________ _________________________ Supervisor's Signature Date Supervisor must submit a copy of transcripts documenting advanced degree in behavioral science or CDCS certificate. RICB 8
CLINICAL SUPERVISOR’S EVALUATION INFORMATION I have given the Clinical Supervisor’s Evaluation Form to the following Clinical Supervisor: Name: Name of Employer: Address: City: State:
Zip: Phone: Email:
RICB reserves the right to request further information from all employers and other persons listed on the application form. The RICB and its review committees reserve the option to request an oral interview with the applicant. This information will be used strictly to evaluate the professional competence of a counselor and will be kept confidential by RICB. Further information may be requested in order to verify training, employment, etc. This information is not available to other persons without the written consent of the applicant. RICB 9
CLINICAL SUPERVISOR’S EVALUATION FORM Dear Clinical Supervisor: Your employee named on the accompanying form is applying to RICB for certification as a Chemical Dependency Clinical Supervisor (CDCS). The information requested here is an essential part of RICB’s evaluation of the competence of the applicant and must be on file before the application can be processed. It is vital that you complete the Evaluation Form accurately. RICB believes that you, as a clinical supervisor, will have developed a more complete and accurate impression of the knowledge and skills of the applicant than is available from other sources. Your evaluation together with those received from other references and the data furnished by applicant will be used to determine eligibility for certification. The process can be only as good as you and others make it by careful and truthful reporting. The RICB reserves the right to request further information from you concerning this applicant. Your cooperation will be very much appreciated in this effort. Please return the completed evaluation along with documentation of the above clinical supervisor requirements. The evaluation must be signed by both the applicant and the evaluator indicating that the evaluation has been shared and is agreeable to both parties. Sincerely, RICB 298 S. Progress Avenue Harrisburg, PA 17109 Fax: 717‐540‐4458 RICB 10
CLINICAL SUPERVISOR’S EVALUATION FORM Applicant Name: Date:
Clinical Supervisor: Credentials:
Phone: Email:
The following items represent the skills needed by a CDCS. Evaluate the above named applicant as you feel he/she demonstrates their abilities in each area. Mark the rating most nearly descriptive of the clinical supervisor’s demonstrated skills. Applicants must earn an average of three on the rating scale to qualify for this certification. RATING SCALE: 1 is UNSATISFACTORY 2 is SATISFACTORY, BUT NEEDS IMPROVEMENT 3 is SATISFIES REQUIREMENTS 4 is EXCEEDS REQUIREMENTS ABILITY TO FACILITATE LEARNING ____ 1. Able to minimize threat, resistance, defensiveness ____ 2. Commitment to teaching, involvement in providing quality supervision, sees supervision as a priority ____ 3. Able to give emotional support ____ 4. Utilizes a variety of supervisory methods/tools e.g. process recording, audio recording, direct observation, case conferences, etc. ____ 5. Able to transmit knowledge effectively ____ 6. Attempts to explain the concepts relevant to the handling of a case rather than the specifics of what the counselor should do ____ 7. Makes appropriate recommendations to counseling staff as to specific training and staff development needs ____ 8. Is responsive to differing points of view SUPERVISORY INTERVENTION SKILLS ____ 1.Demonstrates ability to assess when to offer assistance, when to leave the problem with the counselor, and when to suggest the use of other agency resources in the interest of the client ____ 2. Able to handle disagreements in supervision ____ 3. Able to work out differences with supervisee‐supervisory style ____ 4. Able to use therapeutic interventions when indicated ____ 5. Aware of the interpersonal dynamics of supervisory relationship ____ 6. Able to diagnose and respond to supervisee’s learning needs ____ 7. Able to diagnose and modify difficulties in the supervisory relationship ____ 8. Able to foster the personal growth of supervisee ____ 9. Sees supervision as a two‐way learning and growth activity ____ 10. Encourages continuous processing of the supervisory relationship ____ 11. Able to be an ombudsperson and advocate for supervisee(s) ____ 12. Ability to express feelings directly in supervision rather than concealing them/acting them out ____ 13. Ability to acknowledge own role in any supervisory difficulties ____ 14. Awareness of personal issues affecting response to the material supervisee’s clients present ____ 15. Offers complimentary evaluative feedback in a sensitive and effective manner ____ 16. Offers corrective evaluative feedback in a sensitive and effective manner ____ 17. Communicates complimentary feedback in a clear and concise manner ____ 18. Communicates corrective feedback in a clear and concise manner RICB 11
PERSONAL AND PROFESSIONAL DEVELOPMENT ____ 1. Level of interest in working on own personal growth ____ 2. Level of interest in continuous professional development ____ 3. Responsibility in meeting supervisory duties ____ 4. Awareness of limitations in supervisory skills ____ 5. Awareness of strengths in supervisory skills ____ 6. Uses authority appropriately ____ 7. Has sufficient competence in clinical casework to facilitate work of counseling staff ____ 8. Capable of assessing the performance and the professional development of casework staff ABILITY TO BE A ROLE MODEL ____ 1. Level of influence ____ 2. Able to model attitudes towards clients when discussing their material ____ 3. Promotes attitude of accountability regarding outcome of clinical work, ethical standards, etc. ABILITY TO DIRECTLY TEACH THEORY AND PRACTICE ____ 1. Able to teach assessment skills ____ 2. Able to teach an integrated treatment approach ____ 3. Able to communicate theoretical formulations ____ 4. Able to teach a development of treatment plan ____ 5. Able to teach understanding of assessment and therapy interventions as a process ____ 6. Able to provide effective case‐oriented supervision ____ 7. Able to teach general principles of growth and change ADMINISTRATIVE/MANAGERIAL ABILITIES ____ 1. Addresses issues of adequacy and quality of case records ____ 2. Appears to be knowledgeable of general concerns, issues, and trends reflected in agency’s case load ____ 3. Demonstrates appropriate endorsement of agency policy and procedure Applicant signature: ______________________________________________ Date: _________________________ Evaluator signature: _______________________________________________ Date: __________________________ Partially adapted from the Franklin County Mental Health Center’s Supervisor Performance evaluation form. RICB 12
RELEASE (must be notarized below) I hereby request that RICB grant the credential to me based on the following assurances and documentation: I subscribe to and commit myself to professional conduct in keeping with the RICB Code of Ethical Conduct; I hereby certify that the information given herein is true and complete to the best of my knowledge and belief. I also authorize any necessary investigation and the release of manuscripts and other personal information relative to my certification. Falsification of any records or documents in my application will nullify this application and will result in denial or revocation of certification; I consent to the release of information contained in my application and any other pertinent data submitted to or collected by RICB to officers, members, and staff of the aforementioned Board; I consent to authorize RICB to gather information from third parties regarding continuing education and employment and understand that such communication shall be treated as confidential; Allegations of ethical misconduct reported to RICB before, during, or after application for certification is made will be investigated by RICB and could result in the nullification of the application or denial or revocation of certification. I do hereby submit the following information, assurances and release relating to my initial certification or renewal of certification/licensure with the Rhode Island Board for the Certification of Chemical Dependency Professionals (RICB), Rhode Island Board of Licensing for Chemical Dependency Professional (RIBLCDP) and the Rhode Island Department of Health (RIDOH). Signature:__________________________________________ Date:__________________________________ On this the ______ day of ___________________, 201_____, by me _____________________________________ a notary public, the undersigned officer, personally appeared: _________________________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that she/he executed the same for the purposes therein contained. In witness whereof, I hereby set my hand and official seal. Sworn and subscribed before me this ______ day of _________________________, 201_____. ______________________________________________________ SEAL: Notary Public RICB 13
CODE OF ETHICS AND DISCIPLINARY PROCEDURES The entire Code of Ethics can be found on our website at www.ribccdp.com or may be obtained from the office by calling 401‐349‐3822 I have read and understand RICB Code of Ethics and Disciplinary Procedures in its entirety. I do accept all of the principles of RICB’s Code of Ethics and Disciplinary Procedures as prescribed by RICB. Signature:__________________________________________ Date:_____________________________________ RICB 14