COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...
COSIG CONFERENCE BROCHURE.pdf - Drexel University College ... COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...
Application for CCDP LIST OTHER PCB CREDENTIALS YOU HOLD: _____________________________(see Easy Pass for easy, quick application instructions) APPLICATION FOR CCDP ________ OR CCDP DIPLOMATE __________ NAME: ________________________________________________________________________________________________ HOME ADDRESS: _______________________________________________________________________________________ ________________________________________________________________________________________________________ (city) (state) (zip) (email) COUNTY: ____________________________________________ GENDER: (Please circle) MALE FEMALE HOME PHONE: ( )_______________________________ SOCIAL SECURITY # ___________________________ EMPLOYER: _________________________________________ DATE OF BIRTH: _______________________________ EMPLOYER ADDRESS: ______________________________________________________ ZIP CODE:_________________ COUNTY: ________________________________________ EMPLOYER PHONE: ( )_________________________ EMAIL: __________________________________________ HIGHEST DEGREE EARNED:_________________________ NAME OF COLLEGE/UNIVERSITY:______________ NAME ON YOUR TRANSCRIPT, if different than listed above (i.e. maiden name) ____________________________________ DATE YOU REQUESTED TRANSCRIPT SENT TO PCB: __________________________ (include copy of request) If the following is applicable, please complete this part and include a verification letter from agency where internship/practicum was performed and copies of license(s) and specialized credential(s). AGENCY WHERE INTERNSHIP/PRACTICUM WAS PERFORMED: ____________________________________________ LIST RELEVANT STATE ISSUED LICENSE(S): _____________________________________________________________ LIST SPECIALIZED CREDENTIALS: ______________________________________________________________________ Fee of $200 can be paid using one of the following: Check or Money Order to PCB ( ) Check $__________ Credit Card ___________ - __________ - ___________ - ___________ ( ) Money Order $__________ 3-Digit Security Code ______ Expiration Date: _____ /_____ ( ) Visa/Mastercard $__________ Signature___________________________________________________ 5
Work Experience Verification Applicant’s Name_________________________________________________ Title____________________________________ Supervisor’s Name________________________________________________ Title___________________________________ Employer________________________________________________________________________________________________ Supervisor’s Telephone # ( )_____________________________________ Applicant’s dates of employment in counseling From:_____/_____/_____ To:_____/_____/_____ Month Day Year Month Day Year Applicant’s dates of employment providing integrated From:_____/_____/_____ To:_____/_____/_____ services to clients with co-occurring disorders Month Day Year Month Day Year Number of hours worked weekly: ____________ Please give a detailed description of the applicant’s job duties in counseling and integrated services to clients with co-occurring disorders during the above dates of employment. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signature of Supervisor___________________________________________________ Date________________________ NOTE: If more than one employer must document current and relevant previous employment, photocopy this page for each employer. 6
- Page 59 and 60: COSIG Co-Occurring Disorders Confer
- Page 61: 5. Criminal Logic: This is a 3- to
- Page 65 and 66: COSIG Co-Occurring Disorders Confer
- Page 67 and 68: COSIG Co-Occurring Disorders Confer
- Page 69 and 70: COSIG Co-Occurring Disorders Confer
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- Page 75 and 76: 12 Roadblocks of Communication 1 Or
- Page 77 and 78: 3 G.R.A.C.E. G- For Gap. Often our
- Page 79 and 80: 5 _________________________________
- Page 81 and 82: 7 Overall, what do you gain by drug
- Page 83 and 84: 9 2. What time of day would be best
- Page 85 and 86: 11 10. What good things would happe
- Page 87 and 88: 13 Decisional Balance for Drug Use
- Page 89 and 90: 15 ________________________________
- Page 91 and 92: 17 Drug use: Antecedents, Consequen
- Page 93: Certificate of Achievement Temple U
- Page 97 and 98: COSIG Co-Occurring Disorders Confer
- Page 99 and 100: COSIG Co-Occurring Disorders Confer
- Page 101 and 102: COSIG Co-Occurring Disorders Confer
- Page 103: M06: An Overview: Co-Occurring Diso
- Page 107 and 108: Requirements for CCDP Employment CC
- Page 109: ecertification cycle (PCB approved
- Page 113 and 114: Code of Ethical Conduct UNLAWFUL CO
- Page 115 and 116: psychoactive substance impairs the
- Page 117 and 118: Easy Pass for PCB credentialed prof
- Page 119 and 120: CCDP Checklist for applicants with
- Page 122 and 123: TABLE OF CONTENTS Purpose of the Ca
- Page 124 and 125: confidentiality in substance abuse
- Page 126 and 127: Task 4 - Recognize signs and sympto
- Page 128 and 129: individual’s needs and circumstan
- Page 130 and 131: and community resources and service
- Page 132 and 133: 3. Social supports and networks for
- Page 134 and 135: COUNSELING Task 1 - Provide a safe,
- Page 136 and 137: CASE MANAGEMENT information. Task 1
- Page 138 and 139: ensure continuity of care whenever
- Page 140 and 141: disciplinary codes of ethics and st
- Page 142 and 143: 2. Effective public relations techn
- Page 144 and 145: 2. Eliciting accurate evaluation da
- Page 146 and 147: 2. There are seven elements in the
- Page 148 and 149: elationship is established with the
- Page 150 and 151: In taking the test, you may find it
- Page 152 and 153: REFERENCES The following resources
- Page 154 and 155: Other Drug Abuse Counselors. Columb
- Page 156 and 157: Stern, T., Herman, J., & Slavin, P.
- Page 158 and 159: 2004 PA Certification Board (PCB).
Application for CCDP<br />
LIST OTHER PCB CREDENTIALS YOU HOLD: _____________________________(see Easy Pass for easy, quick<br />
application instructions)<br />
APPLICATION FOR CCDP ________ OR CCDP DIPLOMATE __________<br />
NAME: ________________________________________________________________________________________________<br />
HOME ADDRESS: _______________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
(city) (state) (zip) (email)<br />
COUNTY: ____________________________________________ GENDER: (Please circle) MALE FEMALE<br />
HOME PHONE: ( )_______________________________ SOCIAL SECURITY # ___________________________<br />
EMPLOYER: _________________________________________<br />
DATE OF BIRTH: _______________________________<br />
EMPLOYER ADDRESS: ______________________________________________________ ZIP CODE:_________________<br />
COUNTY: ________________________________________ EMPLOYER PHONE: ( )_________________________<br />
EMAIL: __________________________________________<br />
HIGHEST DEGREE EARNED:_________________________ NAME OF COLLEGE/UNIVERSITY:______________<br />
NAME ON YOUR TRANSCRIPT, if different than listed above (i.e. maiden name) ____________________________________<br />
DATE YOU REQUESTED TRANSCRIPT SENT TO PCB: __________________________ (include copy of request)<br />
If the following is applicable, please complete this part and include a verification letter from agency where internship/practicum<br />
was performed and copies of license(s) and specialized credential(s).<br />
AGENCY WHERE INTERNSHIP/PRACTICUM WAS PERFORMED: ____________________________________________<br />
LIST RELEVANT STATE ISSUED LICENSE(S): _____________________________________________________________<br />
LIST SPECIALIZED CREDENTIALS: ______________________________________________________________________<br />
Fee of $200 can be paid using one of the following:<br />
Check or Money Order to PCB<br />
( ) Check $__________ Credit Card ___________ - __________ - ___________ - ___________<br />
( ) Money Order $__________ 3-Digit Security Code ______ Expiration Date: _____ /_____<br />
( ) Visa/Mastercard $__________ Signature___________________________________________________<br />
5
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