Wisconsin Department of Safety and Professional Services
Office Location: 4288 Madison Yards Way LicensE Portal: https://license.wi.gov/
Madison, WI 53705 Email: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DI
VISION OF PROFESSIONAL CREDENTIAL PROCESSING
EMPLOYMENT/VOLUNTEER VERIFICATION FORM FOR
SUPERVISED SUBSTANCE ABUSE COUNSELOR PRACTICE
Please note, according to Wis. Stat. § 440.88(4) a SAC-IT certification may only be renewed twice. The supervised work
experience required for a SAC certification according to Wis. Admin. Code § SPS 161.02(6) must be completed within the
timeframe of the original certification plus two (2) renewal periods.
APPLICANT: Complete this section and forward the form to your clinical supervisor to complete the remainder of the form.
Supervisor must upload completed form directly into LicensE. (Supervisor instructions are below.)
Last Name
First Name
MI
Former / Maiden Name(s)
I am in a position or have an offer for a position, internship, practicum, or an agreement authorizing volunteer hours at an agency
providing substance use disorder treatment per Wis. Admin. Code § SPS 161.01(5)
.
• The supervisor may not permit a supervisee to engage in any substance abuse practice that the supervisee cannot competently
p
erform.
• The supervisor shall not permit a supervisee to engage in any practice that the supervisor cannot competently supervise.
• All supervisors shall be legally and ethically responsible for the supervised activities of the substance use disorder professiona
l
supervisee. Supervisors shall be available or make appropriate provision for emergency consultation and intervention.
Supervisors shall be able to interrupt or stop the supervisee from practicing in given cases or recommend to the supervisee’s
employer that the employer interrupt or stop the supervisee from practicing in given cases, and to terminate the supervise
d
r
elationship, if necessary.
ATTESTATION OF APPLICANT: I declare that I am the person referred to on this form and that all information required to be
completed by me (the applicant for a credential), is complete and accurate to the best of my knowledge and belief. Furthermore, I declare
that after completing the information that was required by me (and only that information) the form was forwarded to the relevant third-
party for completion of the information asked of them. I also declare that to the best of my knowledge the completed form was provided
to the Department of Safety and Professional Services by the relevant third-party (and not by me, the applicant). Finally, I declare that I
understand that failure to provide the requested information, making any materially false statement and/or giving any materially false
information in connection with my application for a credential may result in credential application processing delays; denial, revocation,
suspension, or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. By signing
below, I am signifying that I have read and understand the above declarations.
Applicant Signature (If unable to provide a digital signature print and sign form.)
Date
Application Number
/ /
CLINICAL SUPERVISOR OF SUBSTANCE ABUSE COUNSELORS-IN-TRAINING: Complete this section for the above-
named applicant and return directly to the Department using the LicensE Third-Party* Upload Portal at license.wi.gov. You will
need the application number shown above. (*For form completion purposes, the term “Third-Party” refers to any non-applicant or
non-DSPS individual or entity submitting required documentation in support of a credential application.)
The clinical supervisor shall provide supervision as required per Wis. Admin. Code § SPS 162.01.
Name of Employer
Supervisor’s Printed Name
Continued next page.
#2770 (Rev. 5/4/2023) Page 1 of 2
Wis. Stat. ch. 440
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Supervisor completion, continued.
Supervisor’s Credential Number:
- Phone Number: - -
Credential held by Supervisor:
Clinical supervision may be provided by an intermediate clinical supervisor or an independent clinical supervisor or a physician, licensed
psychologist, professional counselor, marriage and family therapist, clinical social worker, advanced practice social worker, or
independent social worker who practices as a substance abuse clinical supervisor. (Note: Proposed supervisors with temporary or training
licenses require advance review and approval. A credential holder acquiring supervised experience as a substance abuse counselor-in-
training may not practice under the supervision of an individual holding a certificate as a clinical supervisor-in-training.)
1.
I, the supervisor named above, attest that I hold a certificate as a clinical supervisor-in-training. IF YES, you
may NOT serve as a supervisor to a substance abuse counselor-in-training to accrue supervised practice
hours (unless you meet alternate criteria listed in Questions 2 or 4 below).
Yes No
2.
I, the supervisor named above, attest that I hold a temporary or training professional counselor, marriage and
family therapist, clinical social worker, advanced practice social worker, or independent social worker
credential. IF YES, advance review and approval are required. Supervisor must upload with this form
résumé and/or other evidence showing education, training, or experience in addiction treatment. You may
also include a narrative statement explaining how you are knowledgeable in addiction treatment.
Yes No
3.
I, the supervisor named above, attest that I hold a current intermediate clinical supervisor or an independent
clinical supervisor. IF YES, skip Question 4. IF NO, complete Question 4.
Yes No
4.
If no to Question 3, I, the supervisor named above, attest that I hold a permanent, unlimited physician,
licensed psychologist, professional counselor, marriage and family therapist, clinical social worker, advanced
practice social worker, or independent social worker credential and practice as a substance abuse clinical
supervisor. IF NO, advance review and approval are required. Supervisor must upload with this form
résumé and/or other evidence showing education, training, or experience in addiction treatment. You may
also include a narrative statement explaining how you are knowledgeable in addiction treatment.
Yes No
ATTESTATION OF THIRD-PARTY PROVIDING INFORMATION RELATED TO APPLICANT: I declare, on behalf of the
third-party asked to provide information related to the applicant identified on this form, that the information provided is true and correct
to the best of my knowledge and belief. I further declare that after completing the form I, or other third-party staff, will provide the
completed form directly to the Wisconsin Department of Safety and Professional Services for review. By signing below, I am signifying
that I have read, understand, and have complied with the above declarations.
Supervisor’s Signature (If unable to provide a digital signature, please print and sign form.)
Date
/ /
#2770 (Rev. 5/4/2023) Page 2 of 2
Wis. Stat. ch. 440
Committed to Equal Opportunity in Employment and Licensing