Section Alc 316.04 - Additional Materials to be Submitted The additional materials to be submitted by an applicant for initial licensure as a licensed clinical supervisor shall be:
(a) The completed, signed, and notarized form required by the New Hampshire division of state police for the issuance and transmission to the board of the applicant's state and federal criminal conviction reports;(b) A criminal history records check form and fingerprint card or live scan document, requesting both a New Hampshire and a federal records check, in accordance with the procedure specified by the NH department of safety at Saf-C 5700, Operation of the Central Repository: Criminal Records, with the required fee. The fee for the criminal history records check shall be submitted using a separate payment;(c) Unless the information is available only on a secure website, an official letter of verification sent directly to the board from every jurisdiction which has issued a license, certificate, or other authorization to practice clinical supervision stating: (1) Whether the license certificate or other authorization is or was, during its period of validity, in good standing; and(2) Whether any disciplinary action was taken against the licensee, certificate, or other authorization to practice;(d) For the purpose of documenting receipt of the required hours of experience in substance use and co-occurring disorder clinical supervision, as many completed board-provided "Work Experience Report Form" further described in Alc 316.05 as are necessary to document all of the applicant's hours of experience;(e) Applicants for licensure shall request the IC&RC submit proof they have received a passing score on the IC & RC examination directly to the board;(f) For the purpose of documenting receipt of the required hours of training in clinical supervision, as many completed "Clinical Supervisor Training Form" described in Alc 316.06 as are necessary to document all of the applicant's hours of training in clinical supervision; and(g) Original or photocopied certificates indicating the applicant has completed any training listed in Alc 314.04(a)-(c).N.H. Admin. Code § Alc 316.04
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).