Vermont Secretary of State Montpelier VT 05620-3402 (802) 828-2390 diane.lafaille@sec.state.vt.us www.vtprofessionals.org SUPERVISION REPORT INSTRUCTIONS Licensed Alcohol and Drug Abuse Counselor PLEASE READ: The Certified Alcohol and Drug Counselor (ADC) and Licensed Alcohol and Drug Counselor (LADC) licensure is meant for primary counselors, those counselors who are providing addiction treatment as the main focus of their job. Many people in the field have the skills and knowledge of many of the counseling domains. However, if as part of their job they are referring the client to another counselor rather than providing the addiction treatment themselves, then they are not considered an addiction counselor. The process of becoming licensed is guided and overseen by a qualified supervisor (see Rule). The application should not be initiated without the supervisors understanding that they are supervising the applicant towards licensure. The supervisor should review any and all parts of the application prior to submission to the. Dear Supervisor: We appreciate your assistance in our evaluation of your supervisee for licensed and independent practice as a Licensed Alcohol and Drug Abuse Counselor in the State of Vermont. We attach considerable importance to the Supervision Report when we evaluate applicants for licensure. We ask you to give us a thorough description of your supervisee's experience, and performance, as well as the specific nature of the supervision you provided. Feel free to add additional pages if the space provided is not sufficient for you to give an adequate account of your supervisee's work. In completing the attached form, we ask that you: 1. Type or write your responses clearly and legibly. 2. Respond to all questions or provide an explanation for any omissions. If omissions are not explained, the form will be returned. 3. Provide any additional information which you feel is relevant to our evaluation of your supervisee's ability to engage in the independent practice of licensed alcohol and drug abuse counselling. 4. Provide verification of your license. You must have had a minimum of three year s active practice with an unencumbered license. The Verification of Supervisor Licensure form must be sent to this Office directly from the licensing authority of the state in which you were licensed at the time you provided supervision. If you are licensed in Vermont, you may skip this step. Enter your license information of the supervision form. 5. Retain a copy of everything you submit. 6. Forward the completed form and supporting documentation to at the address above. Sincerely,
Vermont Secretary of State Montpelier VT 05620-3402 (802) 828-2390 diane.lafaille@sec.state.vt.us www.vtprofessionals.org LICENSED ALCOHOL AND DRUG COUNSELOR SUPERVISION REPORT (Must be completed by the supervisor) Applicant's name in full: Supervisor s Last Name First Name MI Mailing Address Street/City/State/Zip Telephone E-Mail Do you possess a valid unencumbered LADC license in the state in which the post degree supervised practice occurred and for supervision commencing after the effective date of these rules have a minimum of three year s licensed practice in good standing before supervision begins and is in good standing at all times during the period of supervision? YES NO Do you hold a degree in addiction medicine or addiction psychiatry and practice in the field? YES NO Are you a licensed allopathic or osteopathic physician and board certified in addiction medicine by one of the following: YES NO American Society of Addiction Medicine American Board of Psychology and Neurology, Added Qualification in Addiction Psychiatry Certified in Addiction Medicine by the American Osteopathic Association (AOA) List below every state in which you, the supervisor held a license to practice three years prior to and during the time the supervision took place. Title of your professional license: State License Number Date of Initial License Date Expires(d)
SUPERVISION REPORT PAGE 2 Name of Applicants Post Degree Practice Setting: Address of Applicants Post Degree Practice Setting: Is the Post Degree Supervised Practice Setting one in which the practice of alcohol and drug abuse counselling as defined in 26 V.S.A. 3231 (5) occurred? YES NO Post Degree Supervised Practice Began MM/DD/YY: Post Degree Supervised Practice Ended MM/DD/YY: POST DEGREE SUPERVISED PRACTICE (Graduate Internship and Practica are not applicable) Total number of hours of post degree supervised practice hours worked (minimum 2,000 hours and cannot be accrued in less than one year). Number of direct clinical service hours worked. Direct Clinical Service hours shall include: screening, assessing, treatment planning, counseling, professional and ethical responsibilities. Direct services means providing one to one, group or family services with the primary substance abuser (minimum 1,000 hours). Number of indirect service hours worked. This includes creating case notes, staff meetings, supervision, workshops, conferences, general consultation, teaching, case management activities, and other related work other than direct client contact. We need a break here- another subsection called Post Degree Supervised Practice Supervision (PDSP Supervision must be for a minimum of 1,000 of the 2,000 hours of PDSP. PDSP that is less than 1,000 hours will not be counted. If you as a Supervisor have not provided supervision for 1,000 hours of PDSP, do not complete this section. See Rule 4.19). And have all of these in a box underneath it. Supervision focused on screening, assessment and engagement YES NO Supervision focused on treatment planning, collaboration, and referral YES NO Supervision focused on counseling YES NO Supervision focused on professional and ethical responsibilities YES NO Total number of hours of individual supervision received. (PDSP Supervision must be 1 hour for every 20 hours practice and half of the 100 hours must be individual) Total number of hours of group supervision received. Total number of individual and group supervision received. (The 2,000 hours of PDSP must be accompanied by no fewer than 100 in person face to face Supervision.)
SUPERVISION REPORT PAGE 3 DESCRIPTION OF DUTIES AND SUPERVISION - Please describe in detail the specific nature of supervision. Describe the supervisory methods and the nature of the issues dealt with in supervision. Include a description of the client population served and the applicant s specific duties. ASSESSMENT OF APPLICANTS PERFORMANCE - Please provide a critical evaluation of the applicant's performance and competence, noting strengths, weaknesses and areas for improvement. Include a detailed description and assessment of the applicant s performance which includes: screening, assessment, engagement, treatment planning, collaboration, referral, counseling, professional and ethical responsibilities and other clinical skills supervised.
SUPERVISION REPORT PAGE 4 RECOMMENDATION FOR INDEPENDENT PRACTICE - Please indicate below whether or not you recommend this applicant for independent practice. Please note if you would restrict this applicant to particular areas of clinical practice. Do you recommend this applicant for independent practice? Yes No STATEMENT OF SUPERVISOR I hereby certify that my supervision of applicant met the requirements of Administrative Rule 4.16. I hereby certify that all information I have provided herein is true and accurate to the best of my knowledge. (Signature of Supervisor) (Date)
Vermont Secretary of State Montpelier VT 05620-3402 (802) 828-2390 diane.lafaille@sec.state.vt.us www.vtprofessionals.org VERIFICATION OF SUPERVISOR LICENSURE Name of applicant applying for licensure: Supervisor: Complete the first section of this form and have the state in which you performed the supervision complete the rest. Licensed as a: Date of Birth: First Name MI Last Name & Title (Jr., Sr., II, III, etc.) Former/Maiden P.O. Box Mailing Address: Street/Apt # City/State/Zip Country I hereby authorize the License Agency to furnish to the Vermont the information requested below. Signature Date: Information Below To Be Completed by the Licensing Agency: License # Date Issued: Date Expired: Licensed as a: Licensed By: Examination/Education Endorsement/Reciprocity Waiver License Status Has this license ever been encumbered in anyway (revoked, suspended, limited, surrendered, restricted, placed on probation)? If yes, attach a copy of the decision. Active Inactive Lapsed Yes No Signature of person completing form: Date: State Completing this form: City/State: Telephone: STATE LICENSING AUTHORITY: Mail to: Montpelier, VT 05620-3402 (OFFICIAL SEAL)