IBADCC Evaluation Form (For ACADC, CADC, SUDA)

IBADCC Evaluation Form
This Form is to be filled by Evaluator

For ACADC, CADC, SUDA

Section I. Candidate & Evaluator Information
Candidate *

First Name Last Name
The individual whose name appears above is applying for IBADCC Certification. This designation is reserved for those meeting eligibility criteria and passing a National Written Exam. Candidates who are awarded this designation must demonstrate basic knowledge of working in the area of alcohol and other drug abuse. The information requested of you in this evaluation is an essential component of the evaluation of this candidate for certification. Please consider your observations of this candidate’s work and character as you complete this form.
Evaluator

First Name Last Name
Job Title
Employer
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Observation period from

Month Day Year
Date
Observation period to

Month Day Year
Date
I hereby attest to the ethical professional practice of this candidate and that my responses to this questionnaire have been given freely and voluntarily, and that they are true and complete to the best of my knowledge.
Signature

Clear
Signature date

Month Day Year
Date

Section II. Competency Rating

Choose 1 only

	3 Excellent	2 Satisfactory	1 Unsatisfied	No Observation
Screening The process by which the client is determined appropriate & eligible for admission to a particular program
Intake The administrative & initial assessment procedures for admission to a program
Orientation Describing to the Client the general nature and goals of the program, the rules governing client conduct and infractions that can lead to disciplinary action or discharge for the program: explaining the hours during which services are available, the treatment cost, if any, to be borne by the client, and the client rights
Assessment Those procedures by which a counselor/ program identifies and evaluates weaknesses, strengths, problems needing resolution, establish agreed upon immediate and long-term goals, decides on a treatment process and resources to be utilized
Treatment Planning The process by which the counselor and the client identify and rank problems needing resolution, establish agreed upon immediate and long-term goals, decide on a treatment process and resources to be utilized
Counseling (Individual, Group and significant Other) The utilization of special skills to assist individuals, families, or groups in achieving objectives through: exploring of a problem and its ramifications: examining of attitudes and feelings: consideration of alternative solutions: and decision making
Case Management Activities which bring services, agencies, resources and people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contracts
Crisis Intervention Those services which respond to an alcohol and/or drug abuser’s needs during acute emotion or physical distress
Client Education Provision of information to individuals and groups concerning alcohol and other drug abuse and the available services and resources
Referral Identifying the needs of the client that cannot be met by the counselor or agency, and assisting the client to utilize the support systems community resources available
Reports and Record Keeping Charting the results of the assessment and treatment plan; writing reports, progress notes, discharge summaries and other client-related data
Consultation with Other Professionals in Regard to Client Treatment/ Services Relating with our own and other professionals to assure comprehensive quality care for the client

Section III. Overall Personal Assessment
Please give a general assessment of this candidate’s knowledge and competency of alcohol/drug abuse counseling. Any additional comments on the candidate’s knowledge or competence may be added here.
Assessment
IBADCC reserves the right to request further information from you concerning this applicant.

Click Submit button to send directly, or email the completed form to ibadcc@ibadcc.org.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform