Get Tx Supervised Work Experience Documentation Form 2017-2025

This guide provides a comprehensive overview of the TX Supervised Work Experience Documentation Form and offers clear instructions on filling it out online. Whether you are an intern or a coordinator, this resource is designed to facilitate your completion of the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out the Counselor Intern Information section. Enter the intern's name, including the last name, first name, and middle initial. Include the social security number and ensure that this information is accurate.
3. Provide the mailing address for the intern, including street address, city, state, and ZIP code. Be meticulous to enter the correct information, as it may be used for correspondence.
4. Indicate the Counselor Intern Registration Effective Date and Expiration Date. These dates are crucial for verifying the intern's eligibility.
5. In the CTI Site Information section, fill in the CTI headquarters name and its corresponding CTI number. Complete the site name and telephone number, ensuring accuracy in the contact details.
6. Input the site address, including street address, city, state, and ZIP code for the CTI facility. Accuracy is important for proper documentation.
7. Next, fill out the Training Information. Indicate the dates of service from the start date to the end date. Also, enter the hours worked per week and the job title during this timeframe.
8. Attach a copy of the CTI job description for the designated job title, as this document is essential for review.
9. Specify the total clock hours in KSA domains for the claimed period, ensuring all calculations exclude holidays and other non-working days.
10. For the Qualified Credentialed Counselor Information, indicate whether direct supervision was provided to the intern. If no, provide the name and license number of the supervisor.
11. If the intern has completed 4000 hours, state any reservations regarding their eligibility for a chemical dependency counselor license.
12. Include any additional comments and signatures where required. Ensure the counselor's name, LCDC number, and date are accurate before submission.
13. Finally, the CTI coordinator must sign the form and enter their credentials. Once completed, save any changes made to the form. You can download, print or share the form as needed.

Complete your TX Supervised Work Experience Documentation Form online today to ensure a smooth submission process.