Section Alc 313.07 - Supervised Work Experience Report Forms(a) A component of the application for initial licensure as a licensed alcohol and drug counselor shall be a supervised work experience report form completed for each individual who has supervised the applicant at any agency, program, or other entity providing some or all of the applicant's supervised work experience as described in Alc 306.05.(b) A component of the application for initial licensure as a master licensed alcohol and drug counselor shall be a supervised work experience report form completed for each individual who has clinically supervised the applicant at any agency, program, or other entity providing some or all of the applicant's clinically supervised direct counseling experience in treating substance use disorders as described in Alc 310.05.(c) Enough supervised work experience report forms shall be submitted to the board to cover all of the applicant's experience required by Alc 306.05 or Alc 310.05, as applicable.(d) Each supervised work experience report form required by (a) and (b) above shall be: (1) Completed by: a. As applicable, a supervisor who supervised some or all of the LADC applicant's work experience or a supervisor who clinically supervised some or all of the MLADC applicant's experience in direct counseling treating substance use disorders; orb. An individual responsible for the work of the applicant's original supervisor, if the original supervisor is no longer with the entity providing the applicant's experience; and(2) Completed with the following: a. The information required by (e)(1) through (e)(8) below; andb. The opinion required by (e)(9) below;(3) Signed and dated by the individual completing the report form; and(4) Submitted directly to the board by the individual completing the report form.(e) The supervised work experience report form shall contain:(1) At the head of the form, the name of the applicant;(2) The name of the agency, program, or other entity providing the clinically supervised experience;(3) The address and telephone number of such agency, program, or other entity;(4) The name and title of the supervisor completing and signing the form or the name and title of the replacement in accordance with (d)(1)b. above;(5) Using the "yes" and "no" spaces provided, an indication of whether the supervisor completing the form personally supervised and documented the applicant's work experience;(6) The state(s) in which the supervisor was authorized to practice substance use counseling at the time he or she supervised the applicant;(7) The number(s) of the supervisor's license(s) or other authorization(s) to practice substance use counseling at the time he or she supervised the applicant;(8) The approximate total number of hours the supervisor supervised the applicant; and(9) That supervisor's opinion of the applicant's competence in the performance of each of the 12 core functions, reported by checking off one of the following rating choices pre-printed on the form:c. No opportunity for supervision.(f) The supervisor report form shall also contain the supervisor's dated signature below the following statement preprinted on the form: "I certify that I am aware that the statutory definition of 'clinical supervision' is 'an ongoing regularly occurring process of examination, critique, and improvement of a counselor's skills, directed by the counselor's designated clinical supervisor, and is typically one to one or small group in structure, and utilizes the methods of intensive case review and discussion, and direct and indirect observation of clinical practice. I certify that I, or a supervisor responsible to me, observed and supervised the work of the individual named at the head of this form, and further certify that the information I have provided on this form is true to the best of my knowledge and belief."
(g) The meaning of the signature beneath the statement in (f) above shall be the signer's:(1) Certification that the applicant's supervisor observed and supervised the work of the individual named at the head of the form;(2) Certification that the signer is aware of the quoted statutory definition of "clinical supervision";(3) Certification that the information provided is true to the best of the signer's knowledge and belief; and(4) Acknowledgement that, pursuant to RSA 641:3, the knowing making of a false statement on the form is punishable as a misdemeanor.N.H. Admin. Code § Alc 313.07
Derived From Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12001, Effective 10/13/2016, Expires 10/13/2026.Amended by Number 6, Filed February 9, 2023, Proposed by #13518, Effective 3/13/2023, Expires 3/13/2033 (formerly Alc 313.08) (see Revision Note at chapter heading for Alc 300).