Addiction Worker Accredited Membership Application Form

PRIVATE & CONFIDENTIAL

Addiction Counsellors of Ireland CLG

ADDICTION WORKER ACCREDITED MEMBERSHIP APPLICATION FORM

To assist with your application please refer to Addiction Worker Criteria, Addiction Worker Code of Ethics,
and ACI’s Constitution

Addiction Worker

1. Personal Details

Name:

First

Last

Date of birth:

Contact Number:

Address

City

County

Eircode

Email:

2. Education/Training

2.1) Core Addiction Studies Course title

Name & Address of Training Institute

Start Date

Completion Date

Student Type

Full-time

Part-time

2.1) Qualifications Received

Ensure to attach copies of qualifications

Maximum upload size: 52.43MB

3. Prior Learning

3.1) Submit verification of all relevant education / training courses completed prior to or since completion of core addiction training course and provide relevant photocopies.

Maximum upload size: 52.43MB

3.2) List and verify experience gained either in individual or group process

4. Addiction Worker Practice Hours

4.1) Give details of addiction work practice to date

4.2) Total number of hours practicing in Addiction Worker role – minimum of 1500 hours is required

Please include letters of endorsement from past/current employers

Maximum upload size: 52.43MB

4.3) Was supervison in place?

Yes

5. SUPERVISION

5.1) Have you engaged in Supervision as required (minimum 1 hour per month of practice)?

Yes

5.2) Name of Supervisor

First

Last

5.3) Please provide details of who the Supervisor is accredited by

5.4) Have you a completed Supervisor Report?

Yes

6. ONGOING PROFESSIONAL DEVELOPMENT

Outline your ongoing Professional Development Plan

DECLARATION

I hereby apply to the Addiction Counsellors of Ireland (ACI) for Addiction Worker accredited membership
I agree to adhere to the Code of Ethics & Constitution of ACI
I enclose photocopies of all relevant documentation mentioned in this application

I include relevant Supervisors Reports
I enclose a non-refundable processing fee of €100

I understand that my application may need to be reviewed by scanning my application (password protected) to Accreditation Committee members, therefore I give my permission, please tick

Please tick this box if you agree

Date