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MAADC II Supervised Practicum

[esiggravity formid="119" field_id="2" display="value" ] is applying to the MCB for a Missouri Associate Alcohol Drug Counselor II credential.

Supervised hours must be provided by a MCB qualified supervisor only.

(This cannot be an immediate family member)

INSTRUCTIONS: On this form document the number of supervised hours performed in each domain. The applicant must have completed a total of 300 hours. The applicant must perform a minimum of 10 hours in each domain. The remaining number of hours needed for credentialing can be in any of the domains.

Please enter the requested information and submit this form to the Missouri Credentialing Board

Applicant's Name: [esiggravity formid="119" field_id="2" display="value" ]

MCB Qualififed Supervisor's Name: [esiggravity formid="119" field_id="55" display="value" ]

Agency:

Clinical Supervision Number:

Total Number of Supervised Work Hours (Must be a minimum of 300 hours):

Please indicate on the domain lines below how many of the Total # Supervised Work Hours listed above were in each domain. Thetotal listed on the line above should equal the sum total of the 4 domains (Must be a minimum of 10 hours listed for each domain):

Screening, Assessment & Engagement:

Counseling:

Treatment Planning, Collaboration & Referral:

Professional & Ethical Responsibilities:

Leave this empty:

Your legal name

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August 17, 2018 1:32 pm CST

MAADC II Supervised Practicum 81718 Uploaded by Stacey Langendoerfer - MOCredentialingBoard@gmail.com IP 173.22.130.239