• Clinical Supervisor Approval & Optional Directory Listing

    This form serves two purposes: verification of eligibility to provide clinical supervision and optional inclusion in the WVCBAPP Approved Clinical Supervisor Directory.

  • Supervisory Approval — REQUIRED: All individuals wishing to supervise ADC or AADC credential candidates must complete this form and meet WVCBAPP’s established educational, credentialing, experience, and ethical requirements. Supervisory approval is limited to the level for which the applicant qualifies.

    Public Directory Listing — OPTIONAL: Approved supervisors may choose to have their name and professional contact information published in the WVCBAPP Approved Clinical Supervisor Directory. A directory listing fee applies only to individuals who select this optional service. There is no fee to apply for supervisory approval, and payment is not required to supervise.

    Renewal and Processing: This form must be completed at each applicable credential recertification to maintain supervisory approval and, if selected, continued directory listing. Please allow 4–6 weeks for application review, verification, and directory posting, if requested.

  • Supervisory Eligibility Requirements

    WVCBAPP recognizes different levels of supervisory eligibility based on education and professional credentials.

    • Bachelor’s-level ADC credential holders must also possess the Clinical Supervisor (CS) credential to qualify for supervisory approval.
    • Bachelor’s-level supervisors may supervise ADC candidates only.
    • Bachelor’s-level supervisors are not authorized to supervise master’s-level AADC candidates.
    • Master’s-level ADC credential holders must also possess the CS credential to supervise ADC and AADC candidates.
    • Master’s-level AADC credential holders may supervise both ADC and AADC candidates.
    • Individauls who hold the CS may be eligible to supervise immediately after submission of this form.
    • There is a an additional one-year-post AADC practice requierment for an individual who does not have the CS.  
    • Applicants who do not meet these requirements are not eligible for directory approval or supervisory duties for the ADC/AADC.

  • Applicant Information and Eligibility

  • Format: (000) 000-0000.
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  • Current Qualifying WVCBAPP credential(s)*

  • Current Credentials and Request Details

  • Expiration date ADC/AADC*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Expiration date of CS
     - -
    2 digit month, 2 digit day, 4 digit year
  • Issue Date of ADC/AADC*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Other Licenses and Good Standing

  • Do you hold any other professional license or certification?*
  • Other professional license/certification status*

  • Ethics and Disciplinary History

  • Is the WVCBAPP credential in good standing?*
  • Have you ever been found guilty of an ethics violation or professional misconduct?*
  • Have you ever been denied, suspended, or had any professional license restricted or revoked?*
  • Have you ever been subject to a disciplinary complaint, investigation, or formal review?*
  • Have you ever resigned or surrendered a license/certification while under investigation or disciplinary action?*
  • Have you ever been convicted of, pled guilty to, or entered a no-contest plea to a crime involving dishonesty or professional conduct?*
  • Have you ever had an adverse finding related to fraud, misrepresentation, or failure to disclose information in a professional setting?*

  • Applicant Acknowledgments and Certification

  • Supervisory Responsibilities and Acknowledgments*
  • Ongoing Disclosure and Reporting Responsibilities*
  • Authorization for Verification*
  • Public Directory Consent
  • Applicant Certification*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Approved Clinical Supervisor Directory Listing Fee

    prevnext( X )
    Directory Listing Fee. This optional fee covers placement in the WVCBAPP Approved CS Directory and is NOT required to provide supervision.
    Directory Listing Fee

    This optional fee covers placement in the WVCBAPP Approved CS Directory and is NOT required to provide supervision.  

    $10.00$10.00
      
    Total
    $0.00$0.00

  • Payment Methods

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    Contact Info

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