Supervision and Field Experience - 2080 hours of verifiable field experience and 160 hours of AOD counselor supervision are required under the final regulations. Field Experience may be paid or volunteer. Please copy the following affidavits into your wordprocessor, print them out to be filled out, dated and signed by the appropriate person. Return the affidavits to ACADC Institute, PO Box 8604, Redlands, CA 92375 where they will be added to your student file and made available as part of the public record for proof of requirements met.
AFFIDAVIT OF FULFILLMENT OF 2080 HOURS OF DRUG & ALCOHOL COUNSELING FIELD EXPERIENCE
I, ____________________________________________________, declare that I am the
(supervisor’s name)
_______________________________________________________________________
(title)
of ___________________________________________________________________,
(organization)
______________________________________________________________________,
(supervisor's degree and/or certification designation)
I attest that _____________________________________________________________
(name of applicant)
has worked in our organization no less than ___________________________ hours as a
_____________________________________________________ between the dates of
(Job Title)
___________________,_________ and _____________________, _________.
(month) (year) (month) (year)
My Professional Qualifications are (continue on other side of this page if needed):
MANDATORY: Job title and authority to give human resources information requested, example: Joan Smith, Director, Human Resources, Jarvis Recovery Center.
Supervisor: ______________________________ Date: _____________
Supervisor contact phone: __________________________
AFFIDAVIT OF FULFILLMENT OF 160 HOURS OF COUNSELING SUPERVISION.
I, ____________________________________________________, declare that I am the
(supervisor’s name)
_______________________________________________________________________
(title)
of ____________________________________________________________________.
(organization)
______________________________________________________________________,
(supervisor's degree and/or certification designation)
I attest that _____________________________________________________________
(name of applicant)
has worked under my direct supervision no less than ___________________________ hours as
_____________________________________________________ between the dates of
___________________,_________ and _____________________, _________.
(month) (year) (month) (year)
My Professional Qualifications are (continue on other side of this page if needed):
MANDATORY: Information must include: 1) Certifications, Ordinations, and Licenses with control numbers if applicable; 2) Degrees and Diplomas with names of institutions; 3) Job Title and position at time of supervision of applicant. Example: MAC, NAADAC, Control no. corphq-000-123407, Ph.D., Colorado State University, Diane Lane, Ph.D., Director, Haven House Recovery Center.
Supervisor: ______________________________ Date: _____________
Supervisor contact phone: ___________________________
