California State University, Los Angeles DTLA Campus PROGRAM APPLICATION FOR THE ALCOHOL AND DRUG COUNSELING CERTIFICATE PROGRAM The ualifications for admission to the program are a high school diploma or GED and one year of continuous sobriety for individuals with a substance use history. All students who wish to apply to the program must submit: A completed application form and documentation, which include: 1. A life experience essay (no more than 2 pages double spaced following the attached essay guidelines). 2. One completed and signed recommendation form from a supervisor or professional colleague who can speak to your potential in the field of alcohol and drug counseling. 3. One year continuous sobriety for individuals with a substance use history (list sobriety date below and sign the attached professional conduct statement). 4. One (1) official transcript, or proof of high school diploma or GED. (Official undergraduate transcript can be submitted if high school transcript/diploma are unavailable). Please send all reuired documents, including transcripts to: College of Professional and Global Education, Alcohol and Drug Counseling Certificate Program, ATTN: Judy Impiccini, California State University, Los Angeles, 5151 State University Drive, Los Angeles, CA 90032-8619. Application form can be submitted by Email to: Judy Impiccini, Program Developer, jimpicc@calstatela.edu Last Name First MI of Birth Address City State Zip ( ) Primary Phone Email Sobriety (if applicable) Check one below: I hold a high school diploma from: I currently hold a GED (Submit proof of GED) (Enter name of high school here and submit official transcript) I certify that the statements made by me on this application are truthful and accurate. Signature:
Life Experience Essay Guidelines This essay is part of your evaluation for admission. The Alcohol and Drug Counseling Certificate Program is comprised of college-level courses that include written assignments that are graded on content, as well as grammar and organization. Topic: Write an essay that describes key events in your life experience that motivate you to want to become an alcohol and drug counselor. Guidelines: An essay is an organized discussion in which key points are explained in paragraphs that connect to the main idea. Your writing should use good sentence structure and be free of grammar and punctuation errors. Take time to plan your essay and to proofread your work before submission. Please make sure to include your name on the essay, and submit no more than two double spaced typed pages.
California State University, Los Angeles DTLA Campus Alcohol and Drug Counseling Certificate Program Recommendation Name of Applicant: Last First Middle Maiden Address Phone This letter of recommendation, submitted in support of your admission to this Alcohol and Drug Counseling Certificate Program, will be kept confidential. The Family Education Rights and Privacy Act of 1974 and its amendments, and the California Information Practices Act of 1977 and its amendments, guarantee you access to educational records concerning yourself. You also are permitted by those laws to voluntarily waive that right of access. I waive my right of access to this letter of recommendation form. I do not waive my right of access to this letter of recommendation form. Signature of Applicant: To the Recommender The above person is applying for admission to the Alcohol and Drug Counseling Certificate Program at California State University, Los Angeles. Please submit your opinion of the candidate s potential for a successful career in our academic program. If the student waives his or her right, the recommendation, except as used by the admission officers, will be held in confidence from the student and all other parties. If the student does not waive his or her right, or if the students does not sign the statement above, the student will be permitted to see this form on reuest. Please submit the recommendation directly to: Judy Impiccini, Program Developer Alcohol and Drug Counseling Certificate Program, California State University, Los Angeles College of Professional and Global Education 5151 State University Drive Los Angeles, CA 90032-8201 Signature of recommender Name of recommender (print) Position Institution/Employer Telephone Address Familiarity with applicant (how known, how long, and how well known?)
ACADEMIC PERFORMANCE - If you were responsible for assigning the final grade for one or more academic programs in which the applicant participated, please provide a breakdown of the distribution of grades awarded and show the candidate s class standing for each course in the boxes below. Course Title Applicant grade Applicant rank in class Number of students in class PROFILE - Check ( ) the number that best represents your evaluation of the applicant. 4 = Superior; 3 = Exceeds Expectations; 2 = Satisfactory; 1 = Needs Improvement 4 3 2 1 No basis for judgment Reliability (intellectual and personal integrity, promptness, conscientiousness) Emotional Control (self-control, judgment, consistency, maturity, dependability) Social Values (sensitivity to needs of others) Industry (drive, initiative, work habits, performance) Personality (manners, courtesy, tact, poise) Workplace Skills Oral Communication Skills Written Communication Skills ADDITIONAL COMMENTS: Please include in this section all pertinent information you have regarding the Applicant, particularly: 1) special strengths and weaknesses, 2) any anomalous aspects of applicant's personal, professional, and/or academic record, 3) ability to do independent work, and 4) extracurricular activities including employment. This section is invaluable in deciding among applicants where all else appears eual. If space below is not sufficient, please append additional sheets if necessary or attach a separate letter. Summary Opinion Please check ( ) the one category in which you would rank this applicant according to his/her overall suitability as an alcohol and drug counseling program participant. State what group the applicant is compared to: Excellent - in the upper 10% of applicants I have known Above Average - in the upper 25% of applicants I have known Average Below Average - should be able to complete work in Alcohol and Drug Counseling Poor - not recommended
Professional Code of Conduct for Alcohol and Drug Counseling Students By the very nature of the field you are applying to, students are expected to display certain key behaviors. Upon successful acceptance to the program, any students displaying deficits in one or more of the following behaviors will be reviewed by the faculty and may be subject to disualification from the program. For admission to the program, I will: 1. Perform with integrity and honesty in my academic work and interaction with others. This will affect the manner in which I advance in the program. Forgery and Plagiarism will not be tolerated. 2. Demonstrate professional behavior to faculty, staff and peers. This includes paying attention to instructor, behaving respectfully when there are disagreements, not being disruptive in class, arriving on time, not leaving class early and following my instructors attendance policy. 3. Demonstrate sensitivity and respect for others differences, experiences, culture, values, ideas and opinions. 4. Demonstrate flexibility and openness to ideas and thoughts different from my own, which includes being receptive to feedback from others. 5. Display awareness of my strengths and limitations, including any personal issues that may impede my success as a Drug and Alcohol Counselor. Work to improve upon those limitations. If I become aware, or am made aware, of a personal situation or limitation that can affect my professional effectiveness, including personal physical, psychological or emotional health, I am responsible to take corrective steps and attend personal counseling to remediate such issues. 6. Certify I have maintained at least one year of continues sobriety from the date listed on page one of this application. I understand that discovery of an alcohol or drug relapse will result in immediate expulsion. After expulsion, I understand I would need to reapply to the program after a minimum of one year of additional sobriety. 7. Demonstrate ethical behavior and abiding by the ethical standards of the certifying organization that I decide to align with and the state of California s Code of Conduct. I have read the above behaviors and understand that I am responsible to uphold them if admitted to the Alcohol and Drug Counseling program at Cal State L.A. I understand that if I display deficits in any of these areas during my participation in the program, possible outcomes may include participation in a remediation plan prior to advancing in the program or disualification/dismissal from the program altogether. I also understand the program reuires the completion of 9 courses. A minimum cumulative grade point average of 2.5 is reuired in all course work that applies to the Certificate, with no class lower than a C and a 70% or higher on each course s final exam. Student Signature: Student Name: