MASSACHUSETTS BOARD OF SUBSTANCE ABUSE COUNSELOR CERTIFICATION, INC.
M.B.S.A.C.C.
ADDICTION RECOVERY COACH APPLICATION
APPLICATION FORM
APPLICANT'S NAME
First Name
Last Name
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APPLICANT INFORMATION
NAME:
First Name
Middle Initial
Last Name
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
S.S. #: (last 4)
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
GENDER
MALE
FEMALE
AGENCY:
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOME PHONE:
-
Area Code
Phone Number
CELL:
-
Area Code
Phone Number
WORK PHONE:
-
Area Code
Phone Number
E-MAIL ADDRESS (Home):
example@example.com
E-MAIL ADDRESS (Work):
example@example.com
Due to physical and/or psychological limitations, special accommodations will be required in order for me to take the IC&RC PR exam:
*
YES
NO
(If you checked "yes," an
EXAMINEE REQUEST FOR REASONABLE ACCOMMODATIONS
form will be sent to you. This form must be completed and returned to the certification office a minimum of 90 days prior to the exam.)
SUPERVISOR VERIFICATION FORMS:
List any Supervisors who will be completing a verification form for you.
NAME OF SUPERVISOR (1)
First Name
Last Name
AGENCY (1)
SUPERVISOR'S JOB TITLE (1)
NAME OF SUPERVISOR (2)
First Name
Last Name
AGENCY (2)
SUPERVISOR'S JOB TITLE (2)
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PERSONAL DATA
This application must be returned to MBSACC. It will not be considered complete until all related documents, transcripts, and fees have been received by the Board. Applicant and supervisor answers should be full and complete. Vague and/or incomplete applications will be returned to the applicant causing a delay in the certification review process.
Intentionally false and/or misleading statements could result in denial or revocation of certification.
Please check the box that best describes your ethnic background:
African American/Black
Asian
Caucasian
Hispanic
Native American
(Please Specify)
EDUCATION:
I have earned my:
*
High School Diploma
GED
List highest degree earned:
Name of College/University where degree was earned?
List name on transcript (if different from name on this application):
First Name
Last Name
List any/all MBSACC credentials currently held (i.e., CADC, CCS, etc.):
If you have ever held any other license(s)/certification(s), complete the table below. You must identify the current status of your credential(s) (i.e., Active, Lapsed, Revoked, Suspended, etc.). Failure to disclose all license(s) and/or certification(s) held and current status may result in denial of your application or other appropriate action.
If you have ever received any disciplinary action from another certification or licensing authority, please include a letter of explanation with your application.
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STATE
LICENSE/CERTIFICATION TYPE
LICENSE/CERTIFICATION #
DATE OF ISSUANCE
STATUS
1
2
3
Have you ever been convicted of a felony?
*
Yes
No
(If "Yes," you
must
give a brief description of the felony, the date it occurred, and the result of the conviction on a separate sheet of paper and attach it to the application.)
NOTE:
You are not required to furnish information for any offense committed prior to your 17th birthday or for a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace; or for a conviction of a misdemeanor where the date of such conviction or the completion of any period of incarceration resulting therefrom (whichever is later) occurred five or more years prior to the date of the application, unless you have been convicted of any other offense within five years immediately preceding the date of this application.
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AUTHORIZATION AND RELEASE FORM
I understand that Certification through MBSACC is an entirely voluntary process, and I agree to abide by its policies and procedures for as long as I hold Certification.
I hereby authorize MBSACC, its committees, and staff to make inquiry of any agency, facility, organization, or individual for any additional information that might be necessary to fully and properly evaluate my application for Certification and to investigate my background as it relates to statements contained in the application for Certification.
I hereby authorize MBSACC to contact any of the supervisors listed in my application, and request that each of the supervisors contacted fully and frankly respond to all inquiries made by MBSACC regarding my application.
I hereby release and hold harmless MBSACC, its Board of Directors, Officers, employees, and examiners from any and all manner of suits, actions, claims, and judgments which might arise from such efforts to further document the statements and claims I have made in this application or in the processing or consideration of same.
I further agree to hold free/harmless MBSACC, its Board of Directors, Officers, employees, and examiners from any civil liability for damages or complaints by reason of any action that is within the scope of the performance of their duties which they take in connection with this application and subsequent examinations and/or the failure of MBSACC to issue Certification to me.
I acknowledge, understand, and agree that any falsification or misrepresentation of information by myself or others regarding my experience and/or qualifications will be sufficient reason for disapproval of my application or revocation of my Certification (if granted) at a later date.
Upon submittal of my application, I give permission to MBSACC, its committees, or representatives to contact and question, as necessary, any person, institution, or organization for any ethics or appeals investigation.
You must sign this form in the presence of a witness who is willing to attest to the fact that you signed in his/her presence. The witness must sign where so designated. The witness may be anyone who is familiar with your signature.
APPLICANT NAME (Please print here)
*
First Name
Last Name
WITNESS NAME (Please print here)
*
First Name
Last Name
APPLICANT SIGNATURE
*
WITNESS SIGNATURE
*
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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PROFESSIONAL WORK EXPERIENCE
AN OFFICIAL JOB DESCRIPTION FOR THIS POSITION MUST BE ATTACHED AND MUST BE SIGNED AND DATED BY BOTH THE APPLICANT AND THE SUPERVISOR OF RECORD.
PLEASE NOTE:
In order to become a Certified Addiction Recovery Coach (CARC), the practitioner must possess a familiarity with the entire range of the content Domains of an Addiction Recovery Coach listed below.
AGENCY:
TYPE OF AGENCY:
AGENCY ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
AGENCY PHONE:
-
Area Code
Phone Number
APPLICANT'S JOB TITLE:
SUPERVISOR'S NAME:
First Name
Last Name
SUPERVISOR'S TITLE:
NUMBER OF FULL-TIME HOURS WEEKLY:
NUMBER OF PART-TIME HOURS WEEKLY:
DATES OF EMPLOYMENT: FROM:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TO:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATES OF EMPLOYMENT: FROM:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TO:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TOTAL # OF HOURS WORKED IN THIS POSITION:
OF THE FOLLOWING CONTENT DOMAINS, CHECK AS MANY AS DIRECTLY RELATE TO THIS POSITION:
ADVOCACY
MENTORING & EDUCATION
ETHICAL RESPONSIBILITY
RECOVERY/WELLNESS SUPPORT
In this space, please provide a description of your primary job responsibilities in this position:
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EDUCATION RESUME
The requirement for training/education is a total of 60 hours as follows:
A-D Content Domains for the IC&RC PR Examination-46 hours
A.
Advocacy (minimum of 10 hours required)
B.
Ethical Responsibility (minimum of 16 hours required)
C.
Mentoring/Education (minimum of 10 hours required)
D.
Recovery/Wellness Support (minimum of 10 hours required)
Additional required training areas - 14 hours as listed
E.
Cultural Competency (minimum of 3 hours required)
F.
Addictions 101 (minimum of 5 hours required)
G.
Mental Health (minimum of 3 hours required)
H.
Motivational Interviewing (MI) (minimum of 3 hours required)
Appropriate documentation (i.e., transcript, Certificate of Attendance, etc.) must be provided for each training listed.
Appropriate documentation (i.e., transcript, Certificate of Attendance, etc.) must be provided for each training listed.
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TITLE OF COURSE OR TRAINING
DATE
INSTITUTION (OR INDIVIDUAL OFFERING THE TRAINING)
NUMBER OF TRAINING HOURS/CREDITS
INDICATE CATEGORY OF TRAINING
1
Briefly describe the content of this training -
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TITLE OF COURSE OR TRAINING
DATE
INSTITUTION (OR INDIVIDUAL OFFERING THE TRAINING)
NUMBER OF TRAINING HOURS/CREDITS
INDICATE CATEGORY OF TRAINING
1
Briefly describe the content of this training -
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TITLE OF COURSE OR TRAINING
DATE
INSTITUTION (OR INDIVIDUAL OFFERING THE TRAINING)
NUMBER OF TRAINING HOURS/CREDITS
INDICATE CATEGORY OF TRAINING
1
Briefly describe the content of this training -
Rows
TITLE OF COURSE OR TRAINING
DATE
INSTITUTION (OR INDIVIDUAL OFFERING THE TRAINING)
NUMBER OF TRAINING HOURS/CREDITS
INDICATE CATEGORY OF TRAINING
1
Briefly describe the content of this training -
Rows
TITLE OF COURSE OR TRAINING
DATE
INSTITUTION (OR INDIVIDUAL OFFERING THE TRAINING)
NUMBER OF TRAINING HOURS/CREDITS
INDICATE CATEGORY OF TRAINING
1
Briefly describe the content of this training -
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CODE OF ETHICAL CONDUCT
1. Non-Discrimination
a)
The certified professional shall not discriminate against service recipients or colleagues based on race, ethnicity, religion, national origin, gender, age, sexual orientation, education level, economic or medical condition, or physical or mental ability.
b)
The certified professional should broaden their understanding and acceptance of cultural and individual differences and, in so doing, render services and provide information sensitive to those differences.
2. Competence
a)
The certified professional shall master their specialty's body of knowledge and skill competencies, strive continually to improve personal proficiency and quality of service delivery, and discharge professional responsibility to the best of their ability. The maintenance of competency requires continual learning and professional improvement throughout one's career.
b)
The certified professional should be diligent in discharging responsibilities. Diligence imposes the responsibility to render services carefully and promptly, to be through, and to observe applicable standards.
c)
The certified professional should recognize limitations and boundaries of their own competence and not use techniques or offer services outside those boundaries.
d)
The certified professional should recognize the effect of impairment on professional performance and should be willing to seek appropriate treatment.
3. Romantic/Sexual Misconduct
a)
A certified professional shall, under no circumstances, engage in romantic/sexual contact with service recipients, whether such contact is consensual or forced. This prohibition applies to both in person and electronic interactions or relationships.
b)
A certified professional shall not engage in romantic/sexual activities or romantic/sexual contact with the service recipient's relatives or other individuals with whom the service recipient maintains a close personal relationship when there is a risk of exploitation or potential harm to the service recipient.
c)
A certified professional shall not engage in romantic/sexual activities or romantic/sexual contact with former service recipients because of the potential harm to the service recipient. This prohibition applies to both in person and electronic interactions or relationships.
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4. Fraud-Related Conduct
a) A certified professional shall not present a false or fraudulent claim, or any proof in support of such claim, to be paid under any contract of certificate of insurance.
b) A certified professional shall not seek to have an employee commit fraud or assist in an act of commission or omission to aid fraud related behavior.
c) An individual shall not use misrepresentation in the procurement of certification or recertification. The term misrepresentation includes, but is not limited to, the misrepresentation of professional qualifications, education, certification, accreditation, affiliations, employee experience, the plagiarism of application and recertification materials, or the falsification of references.
5. Professional Standards
a) A certified professional shall meet and comply with all terms, conditions, or limitations of a certification.
b) A certified professional shall not perform services outside of their area of training, expertise, competence, or scope of practice.
c) A certified professional shall not reveal confidential information obtained as the result of a professional relationship, without prior written consent from the recipient of services, except as authorized or required by law.
I, the undersigned, have read and understand the Addiction Recovery Coach Code of Ethical Conduct. I will, to the best of my ability, adhere to and honor this Code in my professional and personal dealings.
PRINT APPLICANT NAME
*
First Name
Last Name
APPLICANT SIGNATURE
*
DATE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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