Disordered Gambling Treatment Supervision Fellowship

Disordered Gambling Treatment Supervision Fellowship

ProgramApplication

1. Program Overview

Introduction

Thank you for applying to the Disordered Gambling Treatment Supervision Fellowship Program (Fellowship Program). The goal of this program is to prepare clinicians to provide clinical supervision for professionals who are eligible to treat people with disordered gambling.This includes skills such as the ability to provide clinical supervision in person and telephonically, to serve as a trainer on the topic of disordered gambling treatment and serve as a general resource regionally and at the state level on disordered gambling treatment.

The fellowship is comprised of training, clinical consultation, professional development planning and concludes with fellows presenting a case study and professional development plan. Specific program requirements and components are outlined below.

Please complete this application in full and return to Ashley Hartman no later than end of business Friday,September 9th, 2016viae-mail at , fax to 216-431-4133, or mail to 3950 Chester Ave., Cleveland, OH 44114. Applications will not be accepted after September 9th, 2016.

Program Requirements

• Disordered gambling treatment as a scope of practice.
• Ability to supervise under current license or working towards supervisor designation, including LISW-S, LPCC-S, LICDC-CS, MSW, LISW, LPCC, Ph.D, RN-BC, and MD.
• A minimum of 2 yearsof experience in disordered gambling treatmentand a plan to obtain the additional hours needed. This includes experience in assessment including psychosocial interviewing and psychometric testing, intake, individual, family and group counseling and client education.

Expectations of the Program

• Attendance at the Gambling Disorder Supervision Training.
• Attendance at four case consultation calls and four in-person case consultation meetings.
• Attendance at a minimum of three gambling supervision calls. These calls are held monthly on the 4th Friday of the month.
• Attendance and potentially serve as a presenter at the Ohio Problem Gambling Conference.
• Completion of a one on one program progress call with the Fellowship Facilitator.
• Successful completion of an oral case study and professional development plan to the Fellowship Program Advisory Council.
• Attendance at one of the Advanced Gambling Trainings hosted in the state of Ohio
• Completion of additional trainings in person or via webinar is highly encouraged.

Stipend

A stipend of up to $2,500 is available for fellows to assist with program-related costs. Prospective fellows are encouraged to work with their employer regarding travel costs associated with the program.

1. Program Calendar of Important Dates

1. Application Information & Contact Information

Applicant Name (first, middle and last): ______

Maiden Name (if applicable):______

Preferred Mailing Address:

□ Home □Work

Home Phone: ______Work Phone: ______

Mobile Phone: ______Fax: ______

Email: ______

1. Supervisor Status

Candidates for the Fellowship Program must be able to supervise under their current license or be in the process of obtaining their supervisor designation. This includes the following licenses: LISW-S, LPCC-S, LICDC-CS, MSW, LISW, LPCC, Ph.D, RN-BC, or MD.

Clinical Supervisor (if applicable): ______

1. Stipend

Stipend amount requested (up to $2,500 available per fellow) ______

1. Resume

Attach a copy of your most current resume.

1. Gambling Scope of Practice

To participate in the Treatment Supervision Fellowship Program, candidates must demonstrate a scope of practice in gambling disorder treatment. Gambling scope of practice can be demonstrated by either holding or working towards obtaining the Nationally Certified Gambling Counselors (NCGC)/Internationally Certified Gambling Counselor (IGCG) license through the International Gambling Counselor Certification Board (IGCCB) or the gambling endorsement through the Ohio Chemical Dependency Board (OCDB). For Social Workers and Counselors treatment of clients with Gambling Disorder must be added to Scope of Practice with appropriate documentation of training/education hours. Please indicate the license you currently hold or are in the process of obtaining.

□ Nationally Certified Gambling Counselors/Internationally Certified Gambling Counselor

□ Gambling Endorsement

□ Added to Scope of Practice with appropriate training/education

Attach documentation verifying that you hold or are in the process of obtaining the above mentioned license, endorsement or Scope of Practice qualification.

1. Required Work Experience

Applicants must complete two yearsofgambling disorder direct clinical experience. Verify completion of the required hours at the time of application by submitting aGambling Disorder Experience Verification Form and Supervisor Reference Form.

1. References

Two clinical references are required. Attach two letters of recommendation from clinicians that can speak to your experience in disordered gambling treatment.

1. Confirmation of Program Dates

I have received all program related dates, and am able to attend/perform all necessary events/requirements.

______

Signature of Applicant Date

1. Essay

In no more than 500 words, please describe how you will utilize the skills and knowledge gained through this program to advance the gambling disorder treatment field in Ohio. Please attach the essay as a separate document.

1. Personal Information

Have you ever had a professional license/certificate reprimanded, suspended, revoked, surrendered or in any other way sanctioned? If yes, please attach a written explanation.

□ Yes □ No

Do you currently live or work at least 51% of the time in Ohio?

□ Yes □ No

Disordered Gambling Treatment Supervision Fellowship

Gambling Disorder Experience Verification Form

This form is provided to document the required two yearsof gambling disorder direct clinical experience.

INSTRUCTIONS TO APPLICANT:

• Complete Part A and sign the Waiver of Liability before giving this form to your supervisor.

PART A: TO BE COMPLETED BY THE APPLICANT

1. Name of Applicant:

______

First Middle Last

1. Employer name and address:

______

______

______

______

1. Job Title of Applicant:

______

WAIVER OF LIABILITY

I, ______hereby authorize ______

(Applicant) (Supervisor)

to provide to Recovery Resources all information which the agency may deem relevant to my qualifications as an applicant for the Fellowship Program. I hereby release and discharge the supervisor from all claims arising out of the provision of such information.

______

Signature of Applicant Date

Disordered Gambling Treatment Supervision Fellowship

Supervisor Reference Form

This form is provided to document the required two years of gambling disorder direct clinical experience.

INSTRUCTIONS TO SUPERVISOR:

• Review Part A of this form. Do not sign this form until you have reviewed Part A.
• Complete Part B ONLY if the waiver of liability has been signed by the applicant.

PART B: TO BE COMPLETED BY SUPERVISOR

1. Name of Supervisor: ______Title:______

1. Professional credentials and/or licenses you hold: ______

1. Name of Applicant supervised: ______

1. Dates you have supervised this Applicant’s gambling disorder direct clinical experience:

From ______to ______

mo/yr mo/yr

Total hours of applicant’s gambling disorder direct clinical experience at this setting: ______

Total number of hours of clinical supervision with this applicant: ______

Delineation of Responsibilities

Please indicate the number of clients and number of sessions spent onduties listed below as completed by the applicant over the course of their experience treating clients with disordered gambling.

Number of ClientsNumber of Sessions

Psychosocial interviews______

Psychodynamic testing ______

Individual counseling ______

Family counseling ______

Group counseling ______

Client education ______

Are you aware of any unethical professional behavior by this applicant?

□ Yes. Please attach an explanation.

□ No

Do you recommend the applicant for the Fellowship Program?

□ Yes.Please provide a letter stating that the applicant will be provided support to attend

all mandatory training dates, case consultation calls and meetings needed to be

successful in this program.

□ No. Please attach an explanation.

I verify the above named individual has completed the above listed hours of gambling disorder direct clinical experience under my supervision.

______

Signature of Supervisor Date

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