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

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

Section 1: Contact Information

* Required Field
*First Name:   *Last Name:   *Application Date:
PERSONAL INFORMATION
*Street 1:
Street 2:
*City: *State: *Zip Code:
*County of Residence:  If you do not live in NJ, pick the NJ county closest to your home.
*Home/Cell Phone:
* E-mail:  
* Confirm 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.
*I identify my gender as:  
 Age:    Ethnicity:

WORK INFORMATION
Are you currently:

*Employment Status (paid or unpaid position, if working at a DMHAS-licensed substance abuse treatment agency)


If you are NOT CURRENTLY working at a DMHAS-licensed agency, attach your resume here and go directly to Section 2 below.
*Employer:
*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 is done via e-mail, so either a home or work e-mail address is required.
* Salary (must include your total reported annual earnings):

*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:
* 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: Experience and Education

* How many experience hours towards the 3000 required for the CADC/LCADC have you completed?

* Please select the highest level of education that you have achieved:





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

 If so, please list type of license/certificate and number.

Transcript Review
If you have taken courses or 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, 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.

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

If you have a Master’s degree in a related field and have not had your transcript reviewed by the Certification Board, please visit http://www.certbd.org for more information.

.
* Do you have a Master’s degree in counseling, social work or a related field?

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   C401 - Addiction Recovery
C101B - Initial Interviewing Process C102 - Biopsychosocial Assessment   C402 - Psychological Client Education
C101C - Initial Interviewing Process C103 - Diagnostic Summaries   C403 - Biochemical/Medical Client…
C102A - Biopsychosocial Assess… C104 - Differential Diagnosis (DSM)   C404 - Sociocultural Client Education
C102B - Biopsychosocial Assess… C105 - Pharmacology and Physiology   C405 - Addiction Recovery and Family Psych. Educ.
C102C - Pharmacology C106 - Perinatal/Fetal Alcohol Spectrum Assessment   C406 - Biochemical and Sociocultural Family Educ.
C103A - Diagnostic Summaries C107 - Compulsive Gambling   C407 - Community and Professional Education
C103B - Diagnostic Summaries C108 - Co-Occurring Disorder Assessment   C408 - Opiate and Stimulant Education
C104 - Compulsive Gambling C109 - Assessment Tools   C409 - Alcohol, Sedative and Hallucinogens
C201A - Introduction to Counseling C201 - Introduction to Counseling   C501 - Ethical Standards
C201B - Introduction to Counseling C202 - Counseling Skills (Introduction to Techniques)   C502 - Legal Aspects
C202 - Introduction to Techniques… C203 - Crisis Intervention   C503 - Cultural Competency
C203 - Crisis Intervention C204 - Addiction Focused Counseling (Individ. Counseling)   C504 - Professional Growth
C204A - Individual Counseling C205 - Group Counseling   C505 - Personal Growth
C204B - Individual Counseling C206 - Family Counseling   C506 - Dimensions of Recovery
C205A - Group Counseling C207 - Cognitive Behavioral Therapy   C507 - Supervision
C205B - Group Counseling C208 - Motivational Interviewing / Motivational Enhancement Therapy   C508 - Community Involvement
C206 - Family Counseling C209 - Pharm. Approaches to Nicotine Dependencies   C509 - Consultation
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          
C402 - Psychological Client Education          
C403 - Biochemical/Medical Client…          
C404 - Sociocultural Client Education          
C405 - Addiction Recovery and…          
C406 - Biomedical/Sociocultural…          
C407A - Community & Professional…          
C407B - Community & Professional…          
C407C - Community & Professional…          
C501 - Ethical Standards          
C502 - Legal Aspects          
C503A - Cultural Competency          
C503B - Cultural Competency          
C504 - Professional Growth          
C505 - Personal Growth          
C506 - Dimensions of Recovery          
C507 - Supervision & Consultation          
C508 - Community Involvement          
     
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 Section 3: Select Your Preferred Training Location * 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.
Bergen County: Children's Aid and Family Services, 22-08 Route 208 South, Fair Lawn – Tuesdays 9:00 a.m. to 4:00 p.m.
Camden County: CCCADA, 1 Alpha Avenue, Voorhees – 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: Wellsprings Center for Prevention and Counseling, 620 Cranbury Road, 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: Agreements

* 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.
* By checking this box, I attest that the information I have supplied is true to the best of my knowledge.

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 Form must be completed for you before your application can be reviewed. This form will be available to download once you click the SUBMIT button below. Please complete it with your supervisor and return to NJPN using the fax number found on the form.