N.H. Admin. Code § Alc 313.09

Current through Register No. 2, January 9, 2025

Section Alc 313.09 - Applicant Evaluation Form

(a) Prospective applicants for initial licensure as a licensed alcohol and drug counselor or master licensed alcohol and drug counselor shall submit a supervision agreement once they are ready to start accruing supervised work hours, even if they have not submitted the completed application form described in Alc 313.02.

(b) The supervision agreement shall contain the following information:

(1) On a page to be completed by the applicant:

a. An indication of whether the applicant is applying for initial licensure as a licensed alcohol and drug counselor or master licensed alcohol and drug counselor;

b. The applicant's name;

c. The applicant's home address;

d. The applicant's email address;

e. The applicant's telephone number;

f. The name of the applicant's employer;

g. The employer's address;

h. The employer's telephone number; and

i. The applicant's position at the place of employment;

(2) On a page to be completed by the applicant's supervisor;

a. The supervisor's name;

b. The business name;

c. The business address;

d. The business email address;

e. The business telephone;

f. The supervisor's position;

g. The supervisor's credentials and license number(s); and

h. If the supervisor is not an employee of the applicant's clinical site, an attached statement which addresses the following:

1. The supervisor's relationship to the candidate's work site;

2. A statement acknowledging the supervisor will provide supervision at the applicant's work site;

3. A copy of a written agreement with the applicant's employer that allows the supervisor to review records and files at the applicant's work site;

4. A statement that the supervisor has knowledge of the applicant's work site policies; and

5. A statement describing how any disagreements between the supervisor and the agency supervisor will be resolved;

(3) The applicant's dated signature below the following certification:

"As the candidate, I agree to provide my supervisor with any and all pertinent information concerning all clients and their care in order to make informed, ethical and efficacious decisions for client care. I will inform my supervisor if I engage in any clinical activities outside of this agreement. My supervisor must authorize all of my clinical activity. I will resolve all ethical dilemmas and practice issues as directed by my supervisor to the best of my ability. This supervision agreement does not remove any legal or civil responsibilities that I have for my actions related to this role"; and

(4) The supervisor's dated signature below the following certification:

"As the supervisor, I agree to provide the candidate with appropriate and efficacious training, guidance and direction to assure a valuable training experience to meet the requirements for licensure as a LADC or MLADC. I specifically acknowledge that I will assume professional and legal responsibility for the candidate and that I will review and have access to the candidate's clinical records. If I cease to supervise the candidate, if my license becomes invalid, restricted, or sanctioned, or if I wish to terminate my legal and professional responsibility for the candidate's acts or omissions, it is my responsibility to so notify the Board and the candidate in writing, and that until I do, I remain responsible."

N.H. Admin. Code § Alc 313.09

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 313.10) (see Revision Note at chapter heading for Alc 300).