Clinical Supervisor for AADC/ADC Initial Certification Application

West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org

Clinical Supervisor of AADC/ADC Initial Certification Add-on Instructions

Applications for CS certification must include the following items. Be prepared to upload the documents with this form:
1. Completed, signed, and notarized “Affirmation of Truth” form (available at www.wvcbapp.org under forms).
2. Valid government-issued photo identification.
3. Current and comprehensive resume.
4. Official Transcripts sent directly to the boad from the university.
5. Signed and dated acknowledgment of the WVCBAPP Code of Ethics (provided within the online application).
6. Verification of supervision hours, signed by both the applicant and their supervisor(s).
7. Candidate must hold a current and valid Alcohol and Drug Counselor (ADC), Advanced Alcohol and Drug Counselor(AADC) or Certified Criminal Justice Professional (CCJP) credential at the reciprocal level.
8. Verification of five (5) years (10,000) hours of counseling experience as an alcohol and other drug use counselor.
9. Verification of two (2) years (4,000) hours of clinical supervisory experience in the alcohol and other drug abuse field. These two (2) years may be included in the five (5) years of counseling experience and must include the provision of 200 contact hours of face-to face or live synchronous supervision clinical supervision. Email this link (form) to your supervisor.
10. Verification of thirty (30) hours of didactic education/training in clinical supervision. This must include education/training in each of the following five domains: Counselor Development, Professional and Ethical Standards, Program Development and Quality Assurance, Assessing counselor Competencies and Performance, and Treatment Knowledge.
11. Payment of the non-refundable application review and examination fee.
*All fees are non-refundable. Checks or money orders should be made payable to: WVCBAPP and mailed to 436 12th St. Suite C, Dunbar, WV 25064. This will delay the application reivew up to 30 days.

Online payments are accepted at https://www.jotform.com/build/250583842211149 using PayPal or by submitting with this form.

*Additional information about initial applications or recertification can be located in the credential's manual available online at: www.wvcbapp.org.
CS Initial Certification Application for AADC/ADC Supervisors

Use this form to apply for the add-on CS credential for the first time. WVCBAPP AADC/ADC Required. DO NOT USE FOR PRSS SUPERVISOR.
Before You Begin the Application

Read the enitre CS manual.

Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.
Date of Initial Application

MonthDayYear
Date
Demographics
Name

First Name Middle NameLast Name
Maiden, Nickname, or Preferred Name:
Optional
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residency Requirement: Initial applicants must live or work in West Virginia at least 51% of the time to qualify. This does not apply to recertification.
Date of Birth

MonthDayYear
Date
Personal E-mail
example@example.com do not use work emails
Phone Number
Format: (000) 000-0000.
Upload Photo ID

Required for exam registration
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Certification Currently Held (select all that apply)

Other
Upload current WVCBAPP ADC/AADC certification certificate

NAADAC issued certifications are NOT accepted
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License Currently Held:

Other
Are you in private practice?
First Year of Employment in the SUD/Prevention Field:
First Year of Employment in the SUD Supervisory Field:
Work Experience
Qualifying Work Experience
To obtain CS certification, applicants must have a minimum of:
- Five (5) years of combined qualifying experience through work as and SUD counslor.
- Verification of two (2) years (4,000) hours of clinical supervisory experience in the alcohol and other drug abuse field. These two (2) years may be included in the five (5) years of counseling experience.
You do not need to list all of your work history. Only enter the number of employers to meet years of qualifying experience.
Do you have at least 2 years of SUD-Specific Supervisory work experience?
Do you have at least 5 years of SUD-Specific Counsling work experience?
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
Is your current employment status?

Other
Is your current job SUD counseling and/or SUD supervision specific work experience?
Describe your current job duties:
Current and Comprehensive Resume

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SUD Counseling/Supervision Specific Former Employment:

Only List SUD Counseling/SUD Supervision Specific Employment in this Section
Former Employer 1
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?
Describe your job duties:
Former Employer 2
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?
Describe your job duties:
Former Employer 3
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?
Describe your job duties:
Former Employer 4
General Work Experience only
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?
Describe your job duties:
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional Former Employer 5
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional
Ethics
Ethical Code of Conduct

It is the policy of the West Virginia Certification Board for Addiction Professionals to promote and safeguard the quality, effectiveness and competence of Prevention Specalist through the insistence of adherence to its Code of Ethics by all WVCBAPP certified CS.

The ethics committee develops and recommends an ethical code of conduct for adoption by the Board of Directors. Currently, the Board has adopted the code of conduct adhered to by IC & RC for the CS, CCJP, PSI, PSII credentials, and NAADAC Code of Ethics for ADC, AADC located at:
www.wvcbapp.org/ethics.

The ethics committee has jurisdiction over all matters of violation and misconduct by WVCBAPP certified CS in the state of West Virginia. It immediately and thoroughly investigates such charges and makes recommendations to the Board of Directors for appropriate action.

AFFIRMATION OF TRUTH:.

I hereby attest that I have read, understand, and will adhere to the IC&RC Code of Ethics for the CS credential including, a subsequent change to the code of ethics that is duly approved by the NAADAC Board of Directors at a regularly scheduled Board Meeting.

It is my responsibility to remain current and comply with the code of ethics for this and other credentials awarded by my credentialing body throughout the life of the credential.

I understand that agreeing and signing below indicates that this application is truthful. Deception on this form is a violation of the Ethical Code of Conduct and may result in sanctions, suspensions or revocations of certification.
Ethical Code of Conduct Affirmation of Truth
Outstanding Ethics Complaints:
Explain any ethical actions filed against you:
Signature
Date

MonthDayYear
Date
Upload Completed Affirmation of Truth (notary form)

Available at www.wvcbapp.org
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Training
To meet the 30 contact hour training requirement, you must provide proper documentation for all training hours.

1. Certificates of Attendance:

• You must upload copies of certificates of attendance for all training hours.

2. College Coursework:

• An official transcript must be sent directly from the institution to wvcbapp@wvcbapp.org. You must have a minimum of a BA/BS to supervise ADC level and a minimun of a MA to supervise AADC level.
- Attaching an unofficial transcript will help us to pair this application to the correct transcript when it is recieved by the Board.
3. Supervisory SUD-Specific Training:

•Verification of thirty (30) hours of didactic education/training in clinical supervision. This must include education/training in each of the following five domains: Counselor Development, Professional and Ethical Standards, Program Development and Quality Assurance, Assessing counselor Competencies and Performance, and Treatment Knowledge.

4. Online Continuing Education Units (CEUs):

• You cannot claim more than 12 online CEUs in a single 24-hour period.
Supervisory SUD-Specific Training Certificate Upload.

30 hours across the domains of Supervision
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Upload Unofficial Transcripts

Optional -It will allow for faster processing time if you upload it. Please have the official transcripts sent to wvcbapp@wvcbapp.org if you are using them for SUD Supervision Specific training.
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Highest Education Level
BS/BA Required for ADC supervision; MA required for AADC supervisors
Have your official transcripts been sent directly to wvcbapp@wvcbapp.org?
What was your legal name at the time of your graduation?
Used to pair the official transcripts to the application.
Provide the name of the institution from which your official transcripts are being sent.
Name of high school/GED or college
Degree Field of Study
Counseling, Social Work etc.
Date Degree was Completed

MonthDayYear
Date
Supervision
To meet the 200 hour supervison requirement, you must provide proper documentation signed by your supervisor(s). The official form is provided at wvcbapp.org in the forms section. Form to email to supervisor It may be printed and attached below or direclty sent to the supervisor to complete.
I have sent the link to my supervisor for completion. https://wvcbapp.jotform.com/261955545452060
Name of Supervisor Completing the form:

First NameLast Name
Upload Signed Supervision Documentation

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Application Review and Exam Fee

Non-refundable
How will you be paying the fee?
Checks and Money Orders will delay application processing times by as much as 30 days.
Pay Fees via PayPal (non-refundable). DO NOT CHECK THE BOXES BELOW IF YOU ARE NOT PAYING USING THIS FORM.
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CS Application Fee
Certification application fee can be paid here, on our website, or via mail.

$125.00

CS Exam Fee
AADC exam fee can be paid here, on our website, or via mail.

$225.00

Total

$0.00
If PayPal was used, what agency or name is on the account?:
Example: Jon Dower or FMRS Health Systems
I affirm that the information contained in this application is true, and that I have attended all training and education uploaded at attached to this document. I adhere to the appropriate Ethical Code of Conduct for my credential(s). Signature
Date

MonthDayYear
Date
Should be Empty:

CS Initial Certification Application for AADC/ADC Supervisors

Demographics

Work Experience

Current Employment:

SUD Counseling/Supervision Specific Former Employment:

Ethics

Training

Supervision

Application Review and Exam Fee

Pay Fees via PayPal (non-refundable). DO NOT CHECK THE BOXES BELOW IF YOU ARE NOT PAYING USING THIS FORM.