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New Jersey Prevention Network
Addiction Training and Workforce Development Program Student Application

The information you supply directly populates your profile in our database. If you provide incomplete or incorrect information, NJPN will be unable to contact you. Please proofread your Application carefully before submitting. Applications that do not meet this criteria will be delayed.

Section 1: Personal Information

* Required Field
*First Name:   *Last Name:   *Application Date:
*Street 1:
Street 2:
*City: *State: *Zip Code:
*County of Residence:
*Home Phone: Cell:
*Home E-mail: If you do not have a personal email, enter your business email.
All communication with scholarship recipients is done via e-mail, so either a home or work e-mail address is required.

Please note:
Complete the employer-related fields below ONLY if you are currently working at a DMHAS-licensed substance abuse treatment agency in either a paid or unpaid position.

If you are NOT CURRENTLY working at a DMHAS-licensed agency, go directly to the Employment Status question below.
*Employment Status (paid or unpaid position, if working at a DMHAS-licensed substance abuse treatment agency)
*Employer (as name appears on DHMAS license):
*Program:
*Position/Title:
*Number of Years with Agency:
*Work Street 1:
Work Street 2:
*Work City:   *Work State:   *Work Zip Code:
*Work Phone:  Extension:
*Work E-mail: If you do not have a business email, enter your personal email.
All communication with scholarship recipients is done via e-mail, so either a home or work e-mail address is required.
*Do you work primarily in the substance abuse treatment unit at a DMHAS-licensed agency?
*Do you work primarily in the mental health unit at a DMHAS-licensed agency?
*Do you work at a state psychiatric hospital?
*Are you a state employee?
*Are you a state contractor?

Clinical Supervisor's Information (complete only if you work at a DMHAS-licensed agency):
*Supervisor's Last Name: *Supervisor's First Name:
*Supervisor's Title:
*Supervisor's Credentials:
*Supervisor's E-mail:
*Supervisor's Phone:

*Employment Status: (for those not currently working at a DMHAS-licensed substance abuse agency).

Are you currently:

General:

*Gender:  
 Age:    Ethnicity:
* Salary (must include your total reported annual earnings):
* I agree to give NJPN the authority to access the results of the LCADC/CADC written and oral exam in order to monitor my progress towards certification or licensure as an alcohol and drug counselor. I understand that NJPN will not publish test results but rather will use this information to evaluate the success of students in the Addiction Training and Workforce Development Program as compared to other CADC candidates who have not received training through NJPN.

Section 2: Education & Experience

* Do you have a (you MUST select each level of education that you have achieved):





Field of Study:

If you have a degree in counseling, social work or a related field and you have had your transcript(s) reviewed by the Addiction Professionals Certification Board (www.certbd.org), please attach a copy of your review letter here so we can verify which of the CADC courses you need to take to complete your LCADC/CADC coursework. You must also indicate all courses not appearing on your Certification Review letter as ALREADY COMPLETED in course index field below (in the right-hand column). (Unmarked ALREADY COMPLETED courses will misrepresent your current needs. Do not indicate ALREADY COMPLETED courses in both columns.)

ONLY the one-page Certification Board Review letter should be uploaded in this area (all other uploads will cause a delay).

* Do you currently possess any counseling or human service related certificates and/or licenses?

 If so, please list type of license/certificate and number.
* How many experience hours towards the 3000 required for the CADC/LCADC have you completed?

Please check the courses which you have ALREADY COMPLETED:
Courses available PRIOR to July 1, 2007: Courses available AFTER July 1, 2007
C101A - Initial Interviewing Process C101 - Initial Interviewing
C101B - Initial Interviewing Process C102 - Biopsychosocial Assessment
C101C - Initial Interviewing Process C103 - Diagnostic Summaries
C102A - Biopsychosocial Assess… C104 - Differential Diagnosis (DSM)
C102B - Biopsychosocial Assess… C105 - Pharmacology and Physiology
C102C - Pharmacology C106 - Perinatal/Fetal Alcohol Spectrum Assessment
C103A - Diagnostic Summaries C107 - Compulsive Gambling
C103B - Diagnostic Summaries C108 - Co-Occurring Disorder Assessment
C104 - Compulsive Gambling C109 - Assessment Tools
C201A - Introduction to Counseling C201 - Introduction to Counseling
C201B - Introduction to Counseling C202 - Counseling Skills (Introduction to Techniques)
C202 - Introduction to Techniques… C203 - Crisis Intervention
C203 - Crisis Intervention C204 - Addiction Focused Counseling (Individ. Counseling)
C204A - Individual Counseling C205 - Group Counseling
C204B - Individual Counseling C206 - Family Counseling
C205A - Group Counseling C207 - Cognitive Behavioral Therapy
C205B - Group Counseling C208 - Motivational Interviewing / Motivational Enhancement Therapy
C206 - Family Counseling C209 - Pharm. Approaches to Nicotine Dependencies
C301A - Community Resources C301 - Community Resources
C301B - Community Resources C302 - Consultation
C301C - Community Resources C303 - Documentation
C30A - Consultation C304 - HIV & Resources
C302B - Consultation C305 - New Jersey Mental Health Services
C302C - Consultation C306 - New Jersey Child and Family Services
C303A - Documentation C307 - Criminal Justice System
C303B - Documentation C308 - New Jersey Disability Services
C304 - HIV-Positive Resources C309 - New Jersey Employment Services
C401 - Addiction Recovery C401 - Addiction Recovery
C402 - Psychological Client Education C402 - Psychological Client Education
C403 - Biochemical/Medical Client… C403 - Biochemical/Medical Client…
C404 - Sociocultural Client Education C404 - Sociocultural Client Education
C405 - Addiction Recovery and… C405 - Addiction Recovery and Family Psych. Educ.
C406 - Biomedical/Sociocultural… C406 - Biochemical and Sociocultural Family Educ.
C407A - Community & Professional… C407 - Community and Professional Education
C407B - Community & Professional… C408 - Opiate and Stimulant Education
C407C - Community & Professional… C409 - Alcohol, Sedative and Hallucinogens
C501 - Ethical Standards C501 - Ethical Standards
C502 - Legal Aspects C502 - Legal Aspects
C503A - Cultural Competency C503 - Cultural Competency
C503B - Cultural Competency C504 - Professional Growth
C504 - Professional Growth C505 - Personal Growth
C505 - Personal Growth C506 - Dimensions of Recovery
C506 - Dimensions of Recovery C507 - Supervision
C507 - Supervision & Consultation C508 - Community Involvement
C508 - Community Involvement C509 - Consultation
If you have taken courses in the topics listed above at an accredited college or university, you may want to contact the Certification Board who will determine if you can receive credit for those courses. Visit http://www.certbd.com/information/qa.htm for more information.

Section 3: Select Your Preferred Training Location

*Please select the location where you would prefer to take courses. Indicate your first choice. (Select a second and third choice only if the sites/days of the week are viable options for you.)
First Choice Second Choice Third Choice Location
Atlantic County: The Arc of Atlantic County, 6550 Delilah Road, Suite 101 Egg Harbor Twp – Saturdays 9 a.m. to 4 p.m.
Camden County: Starting Point, 215 Highland Ave, Westmont – Tuesdays 9:00 a.m. to 4:00 p.m.
Essex County: Newark Renaissance House, 50-56 Norfolk St, Newark – Saturdays 9:00 a.m. to 4:00 p.m.
Hudson County: Endeavor House, 206 Bergen Avenue, Kearny – Wednesdays 9:00 a.m. to 4:00 p.m.
Mercer County: Rescue Mission of Trenton, 98 Carroll Street, Trenton – Saturdays 9:00 a.m. to 4:00 p.m.
Middlesex County: NCADD of Middlesex County, 152 Tices Lane, East Brunswick – Thursdays 9:00 a.m. to 4:00 p.m.
Morris County: Prevention Is Key, 25 West Main Street, Suite 1A, Rockaway – Thursdays 9:00 a.m. to 4:00 p.m.
Ocean County: NJPN, 150 Airport Road, Suite 1400, Lakewood, NJ 08701 – Mondays 9:00 a.m. to 4:00 p.m.

Section 4: *How did you learn about the Addiction Training and Workforce Development Program?

Section 5: *Student Statement

In your own words, please tell us why you should be selected for the Training and Workforce Development Initiative Scholarship program. Include the reason(s) you desire a career in the addictions field and include how the course work will lead to your obtaining your CADC or LCADC.

If you are not CURRENTLY working at a DMHAS-licensed substance abuse treatment or mental health agency or a state psychiatric hospital, please explain what plans you are currently making to secure an internship in order to complete the required 3,000 experience hours needed for certification or licensure.(If you do not fully respond to this inquiry in your Statement, your Application will be delayed.)

Section 6:

If you are not CURRENTLY working at a DMHAS-licensed substance abuse treatment or mental health agency or a state psychiatric hospital, you must attach your resume. (Browse/Open to find your resume and click on Upload File button to complete the attachment. Attachment must be a pdf file.)

If you are CURRENTLY working at a DMHAS-licensed substance abuse treatment or mental health agency or a state psychiatric hospital, a Clinical Supervisor Confirmation (CSC) Form MUST be completed for you BEFORE your Application will be reviewed. (This CSC Form will be available to download once you click the SUBMIT button below.)

* By checking this box, I attest that the information I have supplied is true to the best of my knowledge. I consent to have my supervisor notified if I am not able to be contacted after several class absences or if NJPN has any concerns while I am a student in this program.