Fillable Printable Cdca Application 7.1.11
Fillable Printable Cdca Application 7.1.11
Cdca Application 7.1.11
Chemical Dependency Counselor Assistant
Application
This application must be returned to the Ohio Chemical Dependency Professionals Board. It will not be
considered complete until all related documents, transcripts, and fees have been received by the Board. Applicant
answers should be full and complete. Vague and/or incomplete applications will be returned, causing a delay in
the application process. Intentionally false and/or misleading statements may result in denial or revocation
of certification.
Please type or print legibly.
Applicant Name (first, middle and last)
Maiden Name (if applicable)
Date of Birth
SS #
- -
Preferred Mailing Address (Please provide street number, street name, city, state and zip.)
County
Home Phone
/
-
Work Phone
/
-
Mobile Phone
/
-
FAX #
/
-
E-Mail Address
Would you like to receive correspondences regarding your application via email?
Yes
No
I. PERSONAL HISTORY INFORMATION
Have you ever had a professional license/certificate reprimanded, suspended,
revoked, surrendered or in any other way sanctioned? If yes, please attach a
written explanation.
Yes
No
Have you ever been convicted of a felony? If yes, please complete the felony
questionnaire
Yes
No
Do you currently live or work at least 51% of the time in Ohio?
Yes
No
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II. CHEMICAL DEPENDENCY SPECIFIC EDUCATION GRID
Please list, in chronological order, your chemical dependency counseling education. To meet the requirements for
Chemical Dependency Counselor Assistant certification, applicants must document forty (40) hours of chemical
dependency specific education in the content areas listed below. The minimum number of hours in each area is
identified. These total 40 hours.
Verification of all education hours listed must be included with this application. Acceptable forms of verification
include transcripts, certificates of attendance or letters of verification.
Indicate the number of hours in each content area for which the education/training applies. The content areas are
as follows:
1 - Addiction Knowledge (5 hours)
2 - Treatment Knowledge (9 hours)
3 - Professionalism (6 hours)
4 - Evaluation (3 hours)
5 - Service Coordination (4 hours)
6 - Documentation (3 hours)
7 - Individual Counseling (5 hours)
8 - Group Counseling (5 hours)
Date of
training
Title of training
Total
clock
hours
1 2 3 4 5 6 7 8
TOTAL HOURS THIS PAGE
One semester hour = 15 clock hours One quarter hour = 10 clock hours
DUPLICATE THIS PAGE AS NEEDED AND INCLUDE WITH THE FORMAL APPLICATION
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III. APPLICANT STATEMENT FOR NOTARIZATION
I hereby affirm that I am of good moral character and that all inform ation given herein is true and
complete to the best of my knowledge and belief. I authorize any necessary investigations and/or
release of personal information to the Chemical Dependency Professionals Board and its agents. I
understand that falsification of any portion of this application may result in my being denied
certification/licensure or in revocation of the same.
I hereby affirm that I have read the Chemical Dependency Code of Ethics, and I agree to abide by this
code. (The Chemical Dependency Code of Ethics m ay be accessed at www.ocdp.ohio.gov or may be
sent to an individual upon request.)
I further agree to hold the Chemical Dependency Professionals Board free from any civil liability for
damages or complaints related to any action within the scope and/or arising out of the performance of its
duties, which it or any of its employees may take in connection with this applic ation and/or failure to
issue me said license.
I understand that the $50 fee submitted herewith represents the non-refundable CDCA Form al
Application fee. (A non-refundable $20 fee will be charged for any check not accepted for deposit by
the bank.)
______________________________________________________ ________________________
Applicant Signature Date
Subscribed and sworn before me this _______________ day of ___________ _ ____ ___ _______, 20_________
_____________________________________________________ ________________________
Notary Signature Date Commission Expires
If paying via check or money order:
All checks and money orders should be made payable to “Treasurer, State of Ohio.”
If paying via credit card:
Please complete attached Credit Card Payment Authorization Form.
Please return completed application, including required documentation and fee, to:
Ohio Chemical Dependency Professionals Board
Vern Riffe Center ♦ 77 South High Street, 16th Floor ♦ Columbus, OH 43215
614/387-1110 (phone) 614/387-1109 (fax)
www.ocdp.ohio.gov
Email: [email protected]
FOR OFFICE USE ONLY
Date Received:
Fee Paid:
Check/M.O./C.C. #:
Last Updated 7/11
Credit Card Payment Authorization Form
Please check one:
Master Card
Visa
Cardholder Name:
Address:
City, State, Zip:
Telephone #:
Email Address (for receipt)
Credit Card Number:
Expiration Date:
CVV2/CID Code # (Three digit number on back of card):
Payment Amount:
Payment for (exam, application, etc):
Signature Date
Credit Card Payments may be mailed, faxed, emailed, or phoned in to the Board office.
Ohio Chemical Dependency Professionals Board
77 South High Street, 16
th
Floor Columbus, Ohio 43215
614/387-1110 (phone) 614/387-1109 (fax) www.ocdp.ohio.gov
Email: [email protected]
This document will be shredded after your payment is processed.
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CHEMICAL DEPENDENCY COUNSELOR ASSISTANT
FORMAL APPLICATION CHECKLIST
To facilitate the review of your CDCA formal application and to avoid unnecessary
delays in processing, please use the following checklist when completing the
application. All items on this checklist must be included for your formal application to
be complete and acceptable to the Board. Incomplete or inappropriately completed
applications will be returned and will result in a delay of processing.
Check each item when completed:
Application is complete, signed and notarized
$50.00 application fee enclosed. All fees must be made payable
to Treasurer, State of Ohio.
Felony question has been answered. If you have been previously
convicted of a felony, you will need to complete a felony
questionnaire and submit it with your formal application. Felony
questionnaires are available at
www.ocdp.ohio.gov or by
contacting the Board office.
Education Grid is complete and verification of education hours in
the form of transcripts, certificates and/or letters of completion
have been submitted with this application.
All forms are available at
www.ocdp.ohio.gov or by calling (614) 387-1110.
Last Updated 7/11
Chemical Dependency Counselor Assistant
Education Definitions
Addiction Knowledge - (5 hours)
• Definition of addiction and range of substance related problems
• Biopsychosocial, cultural and spiritual factors related to addictions
• Understanding substances and their effects on brain processes and physiology
• Models and theories of addiction
• Epidemiology of substance use disorders
• Social, political, economic and cultural contexts of addiction and abuse
• History of alcohol and drug enforcement and addictions treatment policies in the US
• Prevention strategies
Treatment Knowledge - (9 hours)
• Models of treatment, recovery, relapse prevention, and continuing care for addiction
• Principles of effective treatment
• Recovery management models
• Appropriateness of treatment to client needs, characteristics, goals, and financial resources
• Historic and evidence-based treatment approaches
• Levels of care
• Stages of change
• Research evaluation
• Interdisciplinary approaches to addiction treatment
• Medical and pharmacological resources in the treatment of substance use disorders
• Helping strategies/engagement strategies
• Treatment planning and methods for monitoring and evaluating progress
Professionalism - (6 hours)
• Professional, legal and ethical parameters of addiction practice
• Interdisciplinary approaches to addiction treatment
• Confidentiality
• Understanding diverse cultures
• Professional licensure and scope of practice
Evaluation - (3 hours)
• Evaluation, screening, assessment and diagnosis of substance use disorders
• Understanding the multi-axial framework of the DSM
• Diagnostic criteria for substance-related disorders
• Differential diagnosis of substance-related disorders, including co-occurring disorders
• Systematic data collection
• Comprehensive assessment process
Service Coordination - (4 hours)
• Levels of care and discharge planning
• Assessing client needs
• Referral processes and resources
• Screening, assessment, and initial treatment-planning information.
• Admission eligibility and readiness for treatment
• Assessing treatment and recovery progress
• Continuing care, relapse prevention, and discharge planning
• Case management
• Community sober supports and relationship building
Documentation - (3 hours)
• Fundamental components of treatment records
• Legal aspects of regulating client treatment
Individual Counseling - (5 hours)
• Facilitating client engagement
• Culturally appropriate models.
• Counseling strategies and techniques related to treatment planning
• Adapting counseling strategies to client characteristics
• Client knowledge, skills, and attitudes
• Crisis intervention
Group Counseling - (5 hours)
• Group process and techniques working with addiction populations
• Culturally appropriate models
• Facilitating member transitions
• Types of groups (ex. Psycho-educational, therapeutic, etc.)
