The applicant shall provide a “Applicant Evaluation Form” to their supervisor, to be completed and returned to the board by the supervisor, which contains the following information:

1. (a) The applicant’s name;
2. (b) The supervisor’s name;
3. (c) The supervisor’s title;
4. (d) The agency or institution at which the supervisor works;
5. (e) The supervisor’s business address;
6. (f) The supervisor’s phone number;
7. (g) The supervisors credentials;
8. (h) The beginning and ending date that the CRSW supervisor supervised the applicant;

9. (i) On the basis of the supervisor’s knowledge of the CRSW applicant, a rating of the applicant’s competency in the following 4 performance domains:

   1. (1) Advocacy;
   2. (2) Ethical responsibility;
   3. (3) Mentoring and education; and
   4. (4) Recovery and wellness support;

10. (j) On the basis of the clinical supervisor’s knowledge of the LADC or MLADC applicant, a rating of the applicant’s 18 categories of competency as follows:

    1. (1) Data collection, including:

       1. a. Knowledge of the elements to be included in a complete client history;
       2. b. Asking appropriate questions which will generate information; and
       3. c. Analyzing data presented relative to accuracy and relevancy;

    2. (2) Diagnosis of alcohol or drug dependence, including:

       1. a. Knowledge of diagnostic indicators of alcohol or drug dependence;
       2. b. Differentiating between substance abuse dependency and alcohol or drug dependency as a primary diagnosis and other social or psychosocial categories
       3. c. Determining appropriateness of admission or referral;
       4. d. Observing and recording behavior not indicated in primary diagnosis;
       5. e. Formulating client’s personal and diagnostic data into meaningful information in order to ensure proper treatment; and
       6. f. Integrating the diagnosis of alcohol or drug dependency with case history;

    3. (3) Initiation of treatment, including:

       1. a. Assessing the motivational level of the client;
       2. b. Determining the type and frequency of treatment necessary;
       3. c. Obtaining a treatment commitment from the client;
       4. d. Setting realistic goals for treatment;
       5. e. Prioritizing goals and objectives;
       6. f. Obtaining mutual understanding between counselor and client of roles, responsibilities, and potential limitations of the treatment process; and
       7. g. Formulating and assisting the client to utilize the treatment plan;

    4. (4) Crisis response, including:

       1. a. Identifying a crisis;
       2. b. Determining its severity;
       3. c. Formulating appropriate crisis response procedures; and
       4. d. Recognizing medical emergencies;

    5. (5) Knowledge of human growth and development, including:

       1. a. Physical, social, emotional, and intellectual development;
       2. b. Deficient developmental patterns;
       3. c. Relating life crisis situations to substance abuse potential;
       4. d. Recognizing the positive and negative influences of the home and family environment on individual development; and
       5. e. Utilizing this knowledge in a systematic and realistic counseling strategy;

    6. (6) Counseling, including:

       1. a. Knowledge of counseling approaches and their underlying theories;
       2. b. Formulating one’s own style of counseling based on these approaches;
       3. c. Implementing one’s approach;
       4. d. Knowledge of functional and dysfunctional dynamics within the counseling situation;
       5. e. Identifying these dynamics within counseling situations;
       6. f. Applying specific counseling approaches in substance abuse counseling; and
       7. g. Coordinating and synthesizing counseling approaches in order to update and individualize treatment plan;

    7. (7) Client and counselor therapeutic relationship, including:

       1. a. Interacting in a manner consistent with the client’s needs;
       2. b. Knowledge of how the physical environment relates to the counseling process;
       3. c. Establishing and maintaining rapport;
       4. d. Assisting the client in gaining insight into unrecognized problems;
       5. e. The ability to empathize;
       6. f. Facilitating the client’s use of problem solving techniques;
       7. g. Interpreting non-verbal behavior; and
       8. h. Accurately communicating information regarding the use of mood altering substances;

    8. (8) Evaluation, including:

       1. a. Receiving and responding to supervisory feedback;
       2. b. Measuring client progress in behavioral terms;
       3. c. Identifying factors responsible for treatment outcome; and
       4. d. Modifying one’s own behavior as agreed upon in supervision;

    9. (9) Termination and follow-up, including:

       1. a. Determining when termination is appropriate;
       2. b. Formulating a discharge plan with the client; and
       3. c. Assisting the client in implementing the discharge plan;

    10. (10) Record keeping, including:

        1. a. Taking notes accurately and compiling information;
        2. b. Documenting client’s progress or lack of the same;
        3. c. Writing a treatment plan;
        4. d. Communicating case information in written form; and
        5. e. Writing a discharge summary;

    11. (11) Verbal communication, including:

        1. a. Communicating a sense of knowledge, confidence, and leadership;
        2. b. Summarizing the treatment process; and
        3. c. Communicating a clear description of client behavior and its relevance to client issues;

    12. (12) Knowledge of regulatory issues, including:

        1. a. Relevant New Hampshire state laws pertaining to substance abuse, intervention, treatment, and counseling;
        2. b. Relevant federal laws; and
        3. c. Regulations governing client confidentiality and client’s rights;

    13. (13) Community utilization, including:

        1. a. Cultural and environmental influences affecting client behavior;
        2. b. Ancillary services offered in the community;
        3. c. Limitations of own and other treatment facilities;
        4. d. Applicable professional literature in the field of substance abuse from state, federal, and private resources;
        5. e. Basic methodology of Alcoholics Anonymous, Alanon, and Alateen;
        6. f. Basic methodology of other alcohol and drug treatment programs;
        7. g. Intervention systems relating to early identification and treatment of substance abuse;
        8. h. The ability to refer to other community resources when appropriate;
        9. i. Incorporating other treatment resources such as consultation, supervision, and education;
        10. j. Contacting and incorporating the family in the treatment process when appropriate;
        11. k. Coordinating the above factors in order to assure systematic treatment; and
        12. l. Demonstrating the use of professional literature in the field of substance abuse;

    14. (14) Knowledge of alcohol and drugs, including:

        1. a. Major classifications of mood altering substances;
        2. b. Most common drugs within each classification;
        3. c. Effects of most common drugs on the human body;
        4. d. Quantitative levels of alcohol and their effects;
        5. e. Drug interaction, synergism, and potentiation; and
        6. f. Resources to identify unknown drugs;

    15. (15) Knowledge of sociological factors, including:

        1. a. Various cultural influences, both past and present;
        2. b. Effects of client’s addictive lifestyle on the family, peer group, and employment situation;
        3. c. Alcohol and drug subculture’s effect involved in supporting the client in the addictive lifestyle;
        4. d. Relationship of substance abuse to other sociological variables such as abuse and neglect, other types of victimization, divorce, and crime; and
        5. e. Sociological factors relating to substance abuse particular to special populations of race, age, sex, occupation, and geographic location;

    16. (16) Knowledge of physiological factors, including:

        1. a. Long and short term physical effects of substance abuse;
        2. b. Long and short term effects of withdrawal;
        3. c. Tolerance, addiction tolerance, and cross tolerance;
        4. d. Neurological effects and body processes involved in recovery;
        5. e. Nutritional effects and body processes involved in recovery;
        6. f. Effect of use and abuse of drugs on prenatal development;
        7. g. Genetic research relating to substance abuse;
        8. h. Physiological and medical factors relating to substance abuse particular to special populations based on race, age, sex, occupation, and geographic location; and
        9. i. The ability to recognize a medical emergency relating to substance abuse;

    17. (17) Knowledge of psychiatric factors, including:

        1. a. Short and long term psychological effects of substance abuse;
        2. b. Psychological factors relating to substance abuse particular to special populations based on race, age, sex, occupation, and geographic location;
        3. c. Recognizing the mentally ill substance abusers;
        4. d. Psychological defense mechanisms; and
        5. e. Psychological effects of withdrawal; and

    18. (18) Knowledge of treatment issues, including:

        1. a. Various treatment components of the continuum of care, including outpatient services, individual, group, and family counseling, inpatient rehabilitation, halfway and quarterway houses, medical detoxification, social setting detoxification, crisis intervention, and aftercare and follow-up;
        2. b. Progression of addiction;
        3. c. Progression of recovery;
        4. d. Appropriate and inappropriate use of psychoactive drugs; and
        5. e. The ability to recognize and verbalize sexual issues as part of treatment;

11. (k) Completion of the following evaluator’s statement by inserting the applicant’s name and the name of the agency or institution, respectively:

    “I hereby certify that I have been in a position to observe and have firsthand knowledge of _____________ work at __________________”;

12. (l) A description of the procedures that the clinical or CRSW supervisor used to supervise and evaluate the applicant; and

13. (m) The clinical or CRSW supervisor’s dated signature and title below the following certification:

    “I hereby certify that all of the above information is, to the best of my knowledge, true.”

Source. #12001, eff 10-13-16; ss by #13518, eff 3-13-23 (formerly Alc 313.10) (see Revision Note for chapter heading for Alc 300)