CERTIFIED ALCOHOL AND DRUG ABUSE COUNSELOR INTERN (CADC-)
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SUPERVISOR’S AGREMENT
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Intern Address_________________________________________
Counselor Interns Name (Print or Type) _____________________________________________________
__________________________________________________________ Supervisor’s License Number
Organization
__________________________________________________________ Co-Supervisors Name___________________________________
Supervisors Name (Print or Type) Co- Supervisors License Number
Organization Phone
Address City State Zip
ARTICLE I Parties
This agreement is made by and between
ARTICLE II Purpose
Intern
and
Supervisor
The purpose of this agreement is the provision of internship supervision for the practice of Certified Alcohol and Drug Abuse Counseling in Nevada as defined by
Nevada Administrative Code 641.C
ARTICLE III Term
This agreement is effective from (date) and will remain in effect until (date) or (Circle) Until Intern
passes the oral examination or supervision agreement has been terminated. Any change in supervision status must be submitted to the Board of Examiners for
Alcohol, Drug and Gambling Counselors within FIVE (5) calendar days.
ARTICLE IV Observation and Six Month Reporting
The Supervisor will provide a minimum of one-hour of individual supervision during each week, where the supervisor and intern review the intern’s activities
during the period. Supervision will also include the supervisor observing the intern conducting a minimum of one counseling session each month.
Supervision will also include the supervisor verifying all educational and CUE’s required during each reporting period.
The supervisor and intern will jointly submit there required 6-month report and notify the Board in writing within five calendar days of any changes in the
supervision status.
In order for a clinical intern to pass the certification examination, the intern must have knowledge and/or experience in all aspects of clinical mental health
counseling. During each supervision period you should evaluate growth/change in each area and identify specific learning activities. The assessment of
knowledge and planning of activities should be made in conjunction with the intern. Use the following codes to evaluate current knowledge.
5 Advanced or full knowledge
4 Intermediate knowledge
3 Basic or entry level knowledge
2 Limited knowledge
1 No knowledge, no training
5 Advanced or full experience
4 Intermediate experience
3 Basic or entry level experience
2 Limited experience in area
1 No experience
This is meant as a tool to guide the intern and supervisor in CURRENT CURRENT PROPOSED ACTIVITIES DURING THE INTERNSHIP
planned activities while preparing for the examination. LEVEL OF LEVEL OF
EXPERIENCE
EXAMINATION CATEGORIES
Section 1. TRANSDISCIPLINARY FOUNDATIONS: The following knowledge and attitudes are prerequisite to the development of competency in
the professional treatment of substance use disorders. Such knowledge and attitudes form the basis of understanding upon which discipline-specific
proficiencies are built.
METHOD OF EVALUATION:
1. Feedback will be provided by the supervisor during each session, and a formal evaluation, using the supervisor’s standard evaluation of
student clinical skills, will be conducted each six months. A narrative evaluation will also be provided at the end of the contracted supervision
time.
2. Specific feedback provided by supervisor will focus on interns ability demonstrated in the following categories:
COUNSELING SKILLS
CLINICAL DOCUMENTATION
ADHERENCE TO ETHICAL AND LEGAL
REQUIREMENTS
PROFESSIONAL READINESS
TREATMENT PLANNING AND THEORIES: A collaborative process through which the counselor and client develop desired treatment
outcomes and identify the strategies for achieving them.
IMPLEMENTING THE TREATMENT PLAN
CONSULTING
CONTINUING ASSESSME3NT & TREATMENT
PLANNING
CLINICAL EVALUATION: The systematic approach to screening and assessment.
SCREENING
ASSESSMENT
RECOMMENCDED CONTINUING
EDUCATION/TRAINING ASSIGNED BY
SUPERVISOR:
Use the following space to describe the proposed working relationship between the supervisor and intern. Discussion should include number of hours worked per
week, activities performed, volunteer versus employed, etc.
ARTICLE
V
-
SUPERVISORS
QUALIFICATIONS
Q
UESTION YES NO
Are you able to demonstrate at least (2) two years of alcohol and drug abuse counseling experience?
Do you hold a current license for LCSW or MFT?
Have you completed the Board approved intern supervisor training?
If not on file with the Board please provide a current copy of the certificate.
Are you related to the applicant?
Are you involved in a close, personal relationship or friendship with the applicant?
Do you have or have you ever had a client relationship with the applicant?
Number of interns currently under your supervision?
Supervisors should be cognizant of the responsibility for supervising interns, please refer to NAC641C.285 for a detailed list of the supervisors duties. Supervisors may be subject
to disciplinary action by the board for non-compliance of supervisory duties and/or held civilly liable by the courts for the practice of interns under their supervision.
Supervisor should be available to consult with the Board about a certified intern being supervised by the licensed counselor concerning the record, competence in practice,
emotional and mental stability, and professional and ethical conduct of the certified Intern.
GENERAL PROVISIONS
This agreement supersedes any and all other agreements, oral or written, between Intern and Supervisor hereto with respect to the rendering of supervision of Intern by Supervisor.
This document contains all of the covenants and agreements between Intern and Supervisor with respect to representations, inducements, promises or agreements, orally or
otherwise, made by any party, or anyone acting on behalf of any party, which are not embodied herein, and that no other agreement, statement or promise not contained in the
agreement will be void.
Any modification of this agreement will be effective only if in writing, signed by Intern and Supervisor, submitted to and approved by the Board of Examiners for Alcohol, Drug
and Gambling Counselors. Such modifications must be in compliance with applicable Nevada Revised Statutes and Nevada Administrative Code and submitted within five days of
any changes. I understand the progress reports runs from January 1 until June 30 and July 1 until December 31 of each year, unless this is the first report. I understand
that all progress reports will be shared with future supervisors and the Board in the event that I apply to the Board for a different supervisor in the future.
I understand it is my responsibility to familiar with the Standards Practice and comply with them.
If any action at law or in equity, including an action for declaratory relief, is brought to enforce or interpret the provisions of this agreement, the prevailing party will be entitled to
reasonable attorney's fees, which may be set for that purpose, in addition to any other relief that the party may be entitled.
This agreement will be governed by and constructed in accordance with the laws of the State of Nevada.
Executed at
City / State
On
Month / Day / Year
Interns Signature Supervisors Signature Co-Supervisors Signature