Form Pds-37 - Casac And Cpp/cps Gambling Specialty Designation Request Form Page 5

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New York State Office of Alcoholism and Substance Abuse Services

CASAC and CPP/CPS Gambling Specialty Designation Request Form

PART B - WORK EXPERIENCE AND TRAINING RECORD

**TO BE COMPLETED BY APPLICANT** (PLEASE PRINT)

APPLICANT CONSENT TO RELEASE INFORMATION

APPLICANT NAME

SOCIAL SECURITY NO.

BY MY SIGNATURE BELOW, I AM AUTHORIZING THE PROVIDER(S)/EMPLOYER(S) AND/OR QUALIFIED HEALTH PROFESSIONAL IDENTIFIED BELOW TO PROVIDE INFORMATION AND

DOCUMENTATION TO THE NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES (OASAS).

APPLICANT SIGNATURE

DATE

WORK EXPERIENCE (CASAC APPLICANTS ONLY)

PROVIDER/EMPLOYER NAME AND ADDRESS

TOTAL SUPERVISED EXPERIENCE AS A PROVIDER OF TREATMENT FOR PROBLEM

DATES OF EMPLOYMENT DURING WHICH TREATMENT FOR

GAMBLERS AND THEIR FAMILIES (NOTE: A MINIMUM OF 30 HOURS MUST HAVE BEEN

PROBLEM GAMBLERS AND THEIR FAMILIES WAS PROVIDED:

DEVOTED TO PRACTICE IN EACH OF THE FOLLOWING THREE AREAS: INDIVIDUAL,

FAMILY

AND

GROUP

COUNSELING;

CRISIS

INTERVENTION;

AND

FINANCIAL

ASSESSMENTS).

TOTAL HOURS

SUPERVISOR (AS DEFINED BELOW) CERTIFICATION (PLEASE PRINT)

NOTE TO SUPERVISOR: PLEASE COMPLETE THIS SECTION OF THE WORK EXPERIENCE AND TRAINING VERIFICATION FORM AND RETURN IT, ALONG WITH DOCUMENTATION TO VERIFY

YOUR STATUS AS A QUALIFIED HEALTH PROFESSIONAL, TO THE APPLICANT.

IF YOU HAVE QUESTIONS RELATED TO THIS FORM, PLEASE CONTACT THE OASAS CREDENTIALING UNIT AT 1-800-482-9564 (Option #1).

I HAVE REVIEWED OUR RECORDS AND CERTIFY THAT THE INFORMATION PROVIDED ON THE WORK EXPERIENCE OF THE ABOVE-NAMED APPLICANT IS TRUE TO THE BEST OF MY

KNOWLEDGE AND BELIEF. BY MY SIGNATURE ON THIS FORM, I ATTEST THAT:

I HOLD A CURRENT STAND ALONE GAMBLING CREDENTIAL OR CASAC CERTIFICATE WITH A GAMBLING SPECIALTY DESIGNATION (ATTACH A COPY OF APPLICABLE CERTIFICATE); AND

HAVE WORKED FOR A MINIMUM OF THREE YEARS AS A PROVIDER OF ALCOHOLISM AND SUBSTANCE ABUSE TREATMENT OR MENTAL HEALTH SERVICES. THIS WORK EXPERIENCE

INCLUDES/INCLUDED: GAMBLING ASSESSMENT AND DIAGNOSIS; INCORPORATING SPECIFIC GAMBLING GOALS INTO TREATMENT PLANS; FINANCIAL EDUCATION AND PLANNING AND

RELAPSE PREVENTION; AND DISCHARGE PLANNING WHICH ADDRESSED(ES) GAMBLING ISSUES. I HAVE AT LEAST ONE YEAR OF CLINICAL SUPERVISORY EXPERIENCE.

I AM A QUALIFIED HEALTH PROFESSIONAL AS DEFINED IN THE PART 800 CHEMICAL DEPENDENCE REGULATIONS (ATTACH A COPY OF YOUR QUALIFIED HEALTH PROFESSIONAL

CERTIFICATE OR LICENSE); AND HAVE WORKED FOR A MINIMUM OF THREE YEARS AS A PROVIDER OF ALCOHOLISM AND SUBSTANCE ABUSE TREATMENT OR MENTAL HEALTH SERVICES.

THIS WORK EXPERIENCE INCLUDES/INCLUDED: GAMBLING ASSESSMENT AND D IAGNOSIS; IN CORPORATING SPEC IFIC GA MBLING GOA LS IN TO TR EATMENT P LANS; FINA NCIAL

EDUCATION AND PLANNING AND RELAPSE PREVENTION; AND DISCHARGE PLANNING W HICH ADDRESSED(ES) GAMBLING ISSUES; AND HAVE COMPLETED 1 5 CLOCK HOURS OF

GAMBLING TRAINING WHICH ADDRESSED THE FOLLOWING AREAS: SCREENING; ASSESSMENT; DIAGNOSIS AND DIAGNOSTIC TOOLS (E.G., SOUTH OAKS GAMBLING SCREEN; DSM-IV

PATHOLOGICAL DIAGNOSIS; LIE-BET; GAMBLER'S ANONYMOUS AND GAM-ANON 20 QUESTIONS TOOL; OR OTHER APPROPRIATE SCREENING INSTRUMENT AS DEFINED BY OASAS); AND

SPECIALIZED TREATMENT INDICATORS FOR GAMBLING (I.E., FINANCIAL, LEGAL, SELF-HELP, CRISIS). I HAVE AT LEAST ONE YEAR OF CLINICAL SUPERVISORY EXPERIENCE.

NAME OF APPLICANT SUPERVISOR

JOB TITLE

SIGNATURE OF APPLICANT SUPERVISOR

WORK TELEPHONE NO.

DATE

TRAINING (CASAC AND CPP/CPS APPLICANTS)

CASAC

CPP/CPS

DATE(S) OF COMPLETION OF 60-HOUR PROBLEM GAMBLING CORE CURRICULUM --

DATE OF COMPLETION OF 30-HOUR PROBLEM GAMBLING CORE CURRICULUM --

TREATMENT TRACK OR INDIVIDUAL TRAININGS WHICH MEET THE OUTLINED

PREVENTION TRACK OR INDIVIDUAL TRAININGS WHICH MEET THE OUTLINED