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Disordered Gambling Treatment Supervision Fellowship Program ApplicationProgram 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, 2016 via e-mail at ahartman@, 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 years of experience in disordered gambling treatment and 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 ProgramAttendance 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 OhioCompletion of additional trainings in person or via webinar is highly encouraged. StipendA 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. Program Calendar of Important DatesEventDateTimeLocationGambling Disorder Supervision TrainingMonday October 3rd, 20169:00 am – 4:30 pm ColumbusOctober Case Consultation CallFriday October 14th, 201612:00 pm – 2:00 pm Conference callNovember Case Consultation MeetingFriday November 18th, 201612:00 pm – 4:00 pm TBDDecember Case Consultation CallFriday December 16th., 201612:00 pm – 2:00 pmConference callJanuary Case Consultation MeetingFriday January 20th, 201612:00 pm – 4:00 pmLouis Stokes VA, ClevelandFebruary Case Consultation CallFriday February 17th, 201612:00 pm – 2:00 pmConference callMarch Case Consultation MeetingWednesday March 1st, 201612:00 pm – 4:00 pmColumbusOhio Problem Gambling ConferenceMarchTwo full daysColumbusApril Case Consultation CallFriday April 14th, 201612:00 pm – 2:00 pmConference callAdvanced Gambling Training Series 1April9:00 am – 4:30 pm Cleveland & ColumbusMay Case Consultation MeetingFriday May 12th, 2016 12:00 pm – 4:00 pm CincinnatiAdvanced Gambling Training Series 2May9:00 am – 4:30 pmCleveland & ColumbusFellow Presentations & GraduationFriday June 30th, 20168:00 am – 4:30 pm Recovery Resources, ClevelandApplication Information & Contact InformationApplicant Name (first, middle and last): ___________________________________________________Maiden Name (if applicable):____________________________________________________________Current Home AddressCurrent Work Address_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Preferred Mailing Address:□ Home □WorkHome Phone: _________________________________ Work Phone: ___________________________Mobile Phone: _________________________________ Fax: _________________________________Email: ______________________________________________________________________________Supervisor StatusCandidates 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.LicenseLicense NumberExpiration DateClinical Supervisor (if applicable): _______________________________________________________Stipend Stipend amount requested (up to $2,500 available per fellow) ___________________________________Resume Attach a copy of your most current resume. 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. Required Work ExperienceApplicants must complete two years of gambling disorder direct clinical experience. Verify completion of the required hours at the time of application by submitting a?Gambling Disorder Experience Verification Form and Supervisor Reference Form.References Two clinical references are required. Attach two letters of recommendation from clinicians that can speak to your experience in disordered gambling treatment. Confirmation of Program Dates I have received all program related dates, and am able to attend/perform all necessary events/requirements. ________________________________________________ ___________________________ Signature of Applicant DateEssayIn 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. Personal InformationHave 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 □ NoDo you currently live or work at least 51% of the time in Ohio? □ Yes □ NoDisordered Gambling Treatment Supervision Fellowship Gambling Disorder Experience Verification FormThis form is provided to document the required two years of 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 Name of Applicant: ______________________________________________________________________________ First Middle LastEmployer name and address: ____________________________________________________________________________________________________________________________________________________________________________________________________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 DateDisordered Gambling Treatment Supervision Fellowship Supervisor Reference FormThis 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 plete Part B ONLY if the waiver of liability has been signed by the applicant. PART B: TO BE COMPLETED BY SUPERVISOR Name of Supervisor: _______________________________Title:__________________________Professional credentials and/or licenses you hold: _____________________________________Name of Applicant supervised: _____________________________________________________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 on duties listed below as completed by the applicant over the course of their experience treating clients with disordered gambling. Number of ClientsNumber of SessionsPsychosocial 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. □ NoDo you recommend the applicant for the Fellowship Program? □ Yes. Please provide a letter stating that the applicant will be provided support to attendall 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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