Section Alc 316.02 - Initial Licensed Clinical Supervisor Application Form The applicant shall furnish the following information on the "Initial Licensed Clinical Supervisor Application Form" provided by the board:
(a) The applicant's full legal name;(b) The applicant's work address;(c) The applicant's work telephone number;(d) The applicant's current license type and license number;(e) The month and year the applicant was originally granted a MLADC or LADC license; and(f) The applicant's physical home address;(g) The applicant's home telephone number or personal cell phone number;(h) The applicant's home e-mail address; and(i) The applicant's dated signature below the following statement preprinted on the "Initial Licensed Clinical Supervisor Application Form": "I certify that at least 2 years (4,000 hours) of my work experience has been clinical supervisory experience in the substance use and integrated co-occurring disorders field and includes a minimum of 200 contact hours of face-to-face clinical supervision that I have provided to others I supervise. I acknowledge that, pursuant to RSA 641:3, the knowing making of a false statement on this application form is punishable as a misdemeanor. I have read Alc 500 and if I am licensed as a clinical supervisor, I promise to abide by them"
N.H. Admin. Code § Alc 316.02
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 (see Revision Note at chapter heading for Alc 300).