09.02.2014
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Supervision To Supervisor: Please complete this form indicating applicant's on-the-job supervision in performing CCDP functions. This form is not intended to document applicant's total number of hours worked but rather the hours of on-the-job supervision you have provided the applicant. Applicant's Name ________________________________________________________________________________________ I hereby attest that a minimum of 300 hours of supervision have been attained by the above-named applicant. At least 10 hours in each of the CCDP performance domains have been provided to the applicant. CCDP PERFORMANCE DOMAINS # HOURS RECEIVED IN EACH 1. Screening & Assessment _________________ 2. Crisis Management _________________ 3. Treatment Planning _________________ 4. Counseling _________________ 5. Case Management _________________ 6. Person, Family, & Community Education _________________ 7. Professional Responsibility _________________ Please also include the following for CCDP Diplomate applicant: 8. Clinical Supervision _________________ 9. Research Design & Application _________________ TOTAL MUST BE AT LEAST 300 HOURS _________________ ____________________________________________ Supervisor's Signature ____________________________________________ Date 7
Code of Ethical Conduct UNLAWFUL CONDUCT Rule 1.1 Once certified, a certified professional shall not be convicted for any misdemeanor or felony relating to the individual’s ability to provide substance abuse and other behavioral health services as determined by PCB. Rule 1.2 A certified professional shall not be convicted of any crime that involves the use of any controlled or psychoactive substance. SEXUAL MISCONDUCT Rule 2.1 A certified professional shall, under no circumstances, engage in sexual activities or sexual contact with clients, whether such contact is consensual or forced. Rule 2.2 A certified professional shall not engage in sexual activities or sexual contact with clients’ relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Rule 2.3 A certified professional shall not engage in sexual activities or sexual contact with former clients because of the potential harm to the client. Rule 2.4 A certified professional shall not provide clinical services to individuals with whom they have had a prior sexual relationship. FRAUD-RELATED CONDUCT Rule 3.1 A certified professional shall not: 1. present or cause to be presented a false or fraudulent claim, or any proof in support of such claim, to be paid under any contract or certificate of insurance; 2. prepare, make, or subscribe to a false or fraudulent account, certificate, affidavit, proof of loss, or other document or writing, with knowledge that the same may be presented or used in support of a claim for payment under a policy of insurance; or 3. present or cause to be presented a false or fraudulent claim or benefit application, or any false or fraudulent proof in support of such a claim or benefit application, or false or fraudulent information, which would affect a future claim or benefit application, or be paid under any employee benefit program; 4. seek to have an employee commit fraud or assist in an act of commission or omission to aid fraud related behavior. Rule 3.2 An individual shall not use misrepresentation in the procurement of certification or recertification, or assist another in the preparation or procurement of certification or recertification through misrepresentation. The term "misrepresentation" includes but is not limited to the misrepresentation of professional qualifications, education, certification, accreditation, affiliations, employment experience, the plagiarism of application and recertification materials, or the falsification of references. Rule 3.3 An individual shall not use a title designation, credential or license, firm name, letterhead, publication, term, title, or document which states or implies an ability, relationship, or qualification that does not exist and to which they are not entitled. Rule 3.4 A certified professional shall not provide service under a false name or a name other than the name under which his or her certification or license is held. Rule 3.5 A certified professional shall not sign or issue, in their professional capacity, a document or a statement that the professional knows or should have known to contain a false or misleading statement. Rule 3.6 A certified professional shall not produce, publish, create, or partake in the creation of any false, fraudulent, deceptive, or misleading advertisement. Rule 3.7 A certified professional who participates in the writing, editing, or publication of professional papers, videos/films, pamphlets or books must act to preserve the integrity of the profession by acknowledging and documenting any materials 8
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Program Description: The Commonweal
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Conference Information: The Pennsyl
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MONDAY May 15 th , 2006
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Monday Morning Plenary Session “S
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M01: The Addiction Psychiatry Couns
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5. Criminal Logic: This is a 3- to
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12 Roadblocks of Communication 1 Or
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3 G.R.A.C.E. G- For Gap. Often our
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5 _________________________________
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7 Overall, what do you gain by drug
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9 2. What time of day would be best
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11 10. What good things would happe
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13 Decisional Balance for Drug Use
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15 ________________________________
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17 Drug use: Antecedents, Consequen
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Certificate of Achievement Temple U
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M06: An Overview: Co-Occurring Diso
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Requirements for CCDP Employment CC
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ecertification cycle (PCB approved
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Work Experience Verification Applic
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psychoactive substance impairs the
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Easy Pass for PCB credentialed prof
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CCDP Checklist for applicants with
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TABLE OF CONTENTS Purpose of the Ca
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confidentiality in substance abuse
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Task 4 - Recognize signs and sympto
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individual’s needs and circumstan
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and community resources and service
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3. Social supports and networks for
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COUNSELING Task 1 - Provide a safe,
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CASE MANAGEMENT information. Task 1
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ensure continuity of care whenever
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disciplinary codes of ethics and st
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2. Effective public relations techn
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2. Eliciting accurate evaluation da
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2. There are seven elements in the
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elationship is established with the
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In taking the test, you may find it
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REFERENCES The following resources
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Other Drug Abuse Counselors. Columb
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Stern, T., Herman, J., & Slavin, P.
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2004 PA Certification Board (PCB).
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Prochaska, J.O. & DiClemente, C.C.,
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M12: An Overview of Adolescents and
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G. Benson, 2004 G. Benson 2004 COSI
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M13: Tri-Recovery Process: Improvin
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M15: TIP 42 Treatment for Persons w
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M16: Housing Implications for the O
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DRAFT - Community Based and Recover
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are perceived as necessary for stat
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esponsibility shared with consumers
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or provided at other rehab programs
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Supportive housing is a successful,
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Living on the Edge: Substance Use a
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M26: Dual Recovery: 12-Step Program
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Using Dialectical Behavior Therapy
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Using Dialectical Behavior Therapy
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TUESDAY May 16 th , 2006
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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Article by Kenneth Minkoff, MD and
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RESOURCE BIBLIOGRAPHY (2005) 1. Ame
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38. Foundation Associates, Making M
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71. Minkoff K & Cline C, Developing
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co-occurring psychiatric and substa
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T31: Implementing Evidence-Based Pr
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T32: Berks County Adolescent Pilot
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T35: CCISC Implementation in Pennsy
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Volume 1, Issue 5 The Trainers meet
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Volume 1, Issue 1 BLAIR COUNTY’S
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Volume 1, Issue 1 Vision/Mission CO
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Volume 1, Issue 1 3. The population
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Volume 1, Issue 1 Complete
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Volume 1, Issue 1 The forgoing Cons
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Volume 1, Issue 1 Language for Inte
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Volume 1, Issue 1 Language for Inte
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T36: The Co-Occurring Distinction:
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Integration or Occupation? •QUEST
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Coming to a Balance “Rather shall
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Motivational Incentives for Enhance
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T43: Prison to Community: Reducing
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Fetal alcohol spectrum disorders fo
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Fetal alcohol spectrum disorders fo
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MY 9-YR-OLD SON’S HISTORY OF MEDI
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Don’t Ask My Child to Fly Bruce R
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1 Multisystemic Therapy MST Model H
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3 NCFAS RESULTS: Adolescents & Pare
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Adelphoi Village Multisystemic Ther
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DISCHARGES PER AGENCY TOTAL DISCHAR
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The following questionnaire is desi
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THE STAGES OF CHANGE APPLIED TO COU
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12. What is the diagnosis: |___| 1
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Fact Sheet A Project to Establish A
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Planning and Implementing a Welcomi
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All organizations signing this memo
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3. Region I organizations will assi
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e) Link organizations with websites
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Planning and Implementing a Welcomi
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Welcome to the Johnson Institute ht
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johnsoninstitute.com - History http
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johnsoninstitute.com - President's
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MISA PILOT TAKES FLIGHT: A PILOT AP
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In Flight Changes for COD in Washin
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Fact Sheet A Project to Establish A
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Mental Health Network Co-Occurring
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Wednesday Morning Plenary Session
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THE BEAVER COUNTY MODEL • Targets
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COSIG Co-Occurring Disorders Confer
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Page 787:
W91: Collaborative Care for Concurr
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Page 790 and 791:
COSIG Co-Occurring Disorders Confer
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Page 792 and 793:
COSIG Co-Occurring Disorders Confer
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Page 795 and 796:
COSIG Co-Occurring Disorders Confer
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Page 797:
COSIG Co-Occurring Disorders Confer
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Page 801 and 802:
COSIG Co-Occurring Disorders Confer
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Page 803 and 804:
COSIG Co-Occurring Disorders Confer
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Page 805:
W96: Stigma & Co-occurring Disorder
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Page 808 and 809:
COSIG Co-Occurring Disorders Confer
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Page 810 and 811:
COSIG Co-Occurring Disorders Confer
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Page 812 and 813:
COSIG Co-Occurring Disorders Confer
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Page 814 and 815:
COSIG Co-Occurring Disorders Confer
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Page 816 and 817:
COSIG Co-Occurring Disorders Confer
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Page 818 and 819:
COSIG Co-Occurring Disorders Confer
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Page 821 and 822:
COSIG Co-Occurring Disorders Confer
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Page 823 and 824:
COSIG Co-Occurring Disorders Confer
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Page 825 and 826:
COSIG Co-Occurring Disorders Confer
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Page 827:
COSIG Co-Occurring Disorders Confer