Missouri Credentialing Board

Fall Renewal MAADC II 9718 wostripe

Attestation Statement - 

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I, [esiggravity formid="124" field_id="2" display="label_value" ], attest I have completed all the necessary hours to renew my MCB credentials for the October 31, 2018 Renewal including all required “live” Ethics hours.
I understand that Missouri Credentialing Board (MCB) has the authority to request my certificates/documentation at any time and it is my responsibility to maintain my training certificates.

I understand that if my renewal is being audited, I must submit a copy of all my training certificates for review.  I further understand that even if I am not being audited, I still must submit a copy of my “live” ethics certificate in order to renew my credentials.  




Renewal Certification Ethics -

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I, [esiggravity formid="124" field_id="2" display="label_value" ] , have read and will abide by the current MCB Treatment Ethics Code and/or the current MCB MRSS, CPS CRPR, BIP or Prevention Ethics Code listed on the website (www.missouricb.com) under the MCB Ethics Code Link.


I, [esiggravity formid="124" field_id="2" display="label_value" ],   hereby certify all of the information given herein is true and complete to the best of my knowledge and belief.  I also authorize any relevant investigations, or the release of personal information to the Missouri Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. 

I understand falsification of any portion of this application/renewal will result in my being denied credentialing, or revocation of same upon discovery.

I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff, peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any action that is within the scope and arise out of the performance of their duties which they, or any of them, may take in connection with this application/renewal, the examination, the grades with respect to any examination, and/or the failure of the MCB to issue me said credential or renewal.

This Authorization and Release shall also apply to personal information requested by the Board at any time following credentialing with connection with any investigation concerning allegations that could lead to disciplinary action against me.

Mentoring and Clinical Supervision Agreement and Professional Development Contract - 

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 Mentoring and Clinical Supervison Agreement

Adapted from Stiehl, R. and Bessey, B. (1994)

I,  [esiggravity formid="124" field_id="2" display="value" ] , agree to work with   [esiggravity formid="124" field_id="139" display="value" ] who is a MCB Qualified Supervisor.

MCB Qualified Supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC, RADC-P, LPC, LCSW, or Licensed Psychologist and has completed the MCB Clinical Supervision Training. This cannot be an immediate family member.  (This form covers both the Mentoring and Clinical Supervision Agreement and Professional Development Contract).

Step 1: Agree to work together

  • Agree on working together toward improving the supervisee’s counseling skills


Step 2: Define and agree on learning goals

  • The learning goals must be clearly defined, and there needs to be agreement to work together to help the supervisee attain proficiency in the skills chosen


Step 3: Understand the value of the goals

  • The supervisee needs to understand the value of achieving the agreed upon goals


Step 4: Break goals into manageable parts

  • The overall goals need to be broken down into parts such as: a) the knowledge, b) the skills, c) the attitudes necessary to attain proficiency


Step 5: Pick styles and methods of learning

  • The supervisor needs to elicit from and negotiate with the supervisee his or her preferred styles and methods of learning


Step 6: Observe and evaluate

  • How progress will be observed and evaluated needs to be discussed and agreed upon


Step 7: Provide feedback

  • The supervisor needs to know how to give feedback which guides, corrects, and at the same time encourages


Step 8: Demonstrate competency and celebrate

  • An outcome demonstration of the newly acquired skill which confirms success needs to be designed, followed by a celebration of the accomplishment



Professional Development Contract

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Purpose, Goals and Objectives of Supervision:

  • Monitor and promote welfare of clients seen by Supervisee
  • Promote development of Supervisee’s professional identity and competence by using the tools learned in the Clinical Supervision: Building Chemical Dependency Counselor Skills Training
  • Oversee Supervisee’s entrance and advancement in the credentialing process
  • Ensure ethical standards are maintained


Supervision Methods:

  • Face to face sessions
  • Supervisee attending trainings (both in-service/outside)
  • File and documentation review
  • Use of forms learned during clinical supervision training (Rubrics, Competency Rating Form, PDP, etc…)
  • Preparing the case presentation when applying for certification


Evaluation of Supervisee:

  • Feedback will be provided during each face to face session
  • A formal evaluation will be conducted every 90 days using the Competency Rating Forms and Professional Development Plan to identify improvement areas


Supervisee Responsibilities:

  • Maintain ethical guidelines and professional standards
  • Improve personal knowledge, skills and attitude by following the Professional Development Plan and advice of supervisor
  • Attend trainings to stay current in the field
  • Perform all duties while keeping the client’s best interest in mind


We agree, to the best of our ability to uphold the guidelines specified in the supervision contract and to manage the supervisory relationship process according to the ethical principles and code of conduct of the MCB. Signing this form covers both the Mentoring and Clinical Supervision Agreement and the Professional
Development Contract.


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Signature Certificate
Document name: Fall Renewal MAADC II 9718 wostripe
lock iconUnique Document ID: a318a3d9308fef9ce352fce0315037c98d91e792
Timestamp Audit
October 12, 2018 7:54 am CSTFall Renewal MAADC II 9718 wostripe Uploaded by Stacey Langendoerfer - MOCredentialingBoard@gmail.com IP