The report form “Supervised Practical Training Report Form” documenting receipt of hours of supervised practical training in alcohol and drug counseling shall require:

1. (a) The information detailed in (b) below to be reported separately for each site of internship, academic program, supervision site, or supervised experience where the applicant received supervised practical training; and

2. (b) The following information shall be provided on the “Supervised Practical Training Report Form”:

   1. (1) The name of the internship, academic program, or work site where the applicant received supervised practical training in alcohol and drug counseling;

   2. (2) The number of hours of supervised practical training received by the applicant in each of the following 12 core functions:

      1. a. Screening;
      2. b. Intake;
      3. c. Orientation;
      4. d. Assessment;
      5. e. Treatment planning;
      6. f. Counseling;
      7. g. Case management;
      8. h. Crisis intervention;
      9. i. Client education;
      10. j. Referral;
      11. k. Reporting and record keeping; and
      12. l. Consultation;
   3. (3) The total hours of supervised practical training in alcohol and drug use counseling;
   4. (4) A certification that the total number of hours of supervised practical training included a minimum of 10 hours of supervised practical training in each of the 12 core functions;
   5. (5) The name(s) and title(s) of the individual(s) providing the supervised practical training or their replacements if the supervisors are no longer available;
   6. (6) The signature(s) of such individual(s) or, if such individual is no longer employed at the same location, of an individual who can attest that the supervised practical training was completed; and
   7. (7) The date of signing.

Source. #12001, eff 10-13-16; ss by #13518, eff 3-13-23 (see Revision Note for chapter heading for Alc 300)