Certified Co-Occurring Disorders Professional Application

Applicant’s Name:
Date:
CCDP/CCDP-D Work Experience (Paid or Internship)
MAKE MULTIPLE COPIES OF THIS PAGE AS NEEDED. USE ONE PAGE FOR EACH EMPLOYER/AGENCY.
Employer: Phone Number: ( )
Address: City: State: Zip Code:
Job Title:
Candidate’s Supervisor:
Was this unpaid/internship experience? YES NO
Average # of hours per week:
To be COMPLETED by candidate and VERIFIED by professional named below
Status: Full time, Part Time, Per Diem, Intern, Volunteer
Still employed? NO
Date you left Agency:
Date of Hire:
Still employed? YES
Today’s Date:
How long in this position (number of years and months)?
Supervisor’s
Initials
Total number of hours worked in this position (Maximum of 2000 per year)
Total number of hours providing co-occurring-specific individual/group counseling
Total number of individual/group clinical supervision hours received
To be completed and signed by candidate’s IDENTIFIED CLINICAL SUPERVISOR ONLY.
Professional’s Name:
Date:
While in this position, this candidate:
Worked with clients with co-occurring disorders? Yes No
Developed and regularly updated recovery/treatment plans with clients Yes No
Provided individual/group counseling for clients with co-occurring disorders? Yes No
Received clinical supervision specific to counseling clients with co-occurring disorders? Yes No
Candidate’s typical number of clients: How long have you supervised the Candidate: years months
I provided clinical supervision to this candidate on site at the agency: YES NO
Number of hours provided:
Supervisor Signature:
Credentials:
Connecticut Certification Board, Inc.
CCDP Application
5
March 2013