Casac Program Application

CASAC PROGRAM APPLICATION

Demographic Questions:

Name: ______

Primary Email Address: ______

Telephone:______Cell Phone: ______

Mailing Address:______

Language Proficiency: (Please circle all that apply) English (1) Speak (2) Read (3) Write

Emergency Contact Information (Please list two people):

Name: ______Relationship: ______Best Contact Info: ______

Education (In order to participate in the CASAC program, applicants must have GED/High school completed): Please attach a copy of the GED/HS Diploma.

Highest Degree attained/ School Name:______

Address of school attended:______

Please include a copy of transcript and /or copy of diploma attached to CASAC Application

Work/Volunteer Experiences (Please attach resume to application):

Current Position:______

Volunteer Position: ______

Top of Form

Personal Statement (Please attach personal statement to application):

Write a personal statement of 500 words or more describing why you want to participate in this training program. (1) Please include any skill sets (2) Describe why you may be a good counselor (3) Why you are interested in the Recovery field.

References( must be listed and a letter must be completed by applicants immediate supervisor and personal person):

Name:______Reference Type:______Phone:______

To be completed by Applicant and their current Employer:

Please list your current employer:

______

Is your employer a provider in the Bronx Lebanon (Bronx Health Access) PPS? Y/N

Please list the projects your organization participates in the BHA PPS?

How will obtaining a CASAC credential best further your organization’s participation/success in the BHA PPS Projects?

To be signed by Employer’s BHA Lead Contact:

Application Check List:

Did applicant complete the following?

Complete Application

Attached Personal Statement

Attached Resume

Attached letters of Reference

Educational Readiness Check List:(TO BE COMPLETED BY ADMISSIONS COMMITTEE)

The checklist below was designed to prescreen the applicant’s readiness for the CASAC Program.Each closed ended question must be answered in the format of “Y,” “N,” or “N/A.” The final scores will be tallied in the end. Applicant must score seven out of the eleven questions listed below.

Did the applicant pass the 4 hour pre screening course?

____ Was the applicant able to provide sufficient information on the application?

Was the attached personal statement written in a clear and concise manner?

Did the applicant understand the personal statement question requirements?

Does the applicant have proof of a High School Diploma or a General Equivalency Diploma (GED)?

Does the client have any hardships which may prevent participation in the program? (i.e. Transportation, medical conditions, ongoing treatment, legal issues, felony, stable housing, child care, etc).

Does the applicant have sufficient business casual work attire for their required Internship?

____ Has the applicant submitted their letters of reference?

_____ Does the applicant have an understanding of the general rules associated with the program requirements? (i.e., attendance requirement, course room rules, total course requirements, projects and presentations etc).

____ Does the applicant have an understanding of cultural competency?

____ Does the applicant have an understanding of “agreeing to disagree?”

____ Send DSRIP YouTube Video to review

Acceptance/Denial into the CASAC Training Program:

All students must required to participate in three screening processes and a 4 hour writing course before a determination is made on the applicants behalf. The first screening process includes: (1) Application Process; (2) Personal Statement; (3) Education Readiness Checklist; and (4) One 4 hour writing and grammar course provided free of charge. All Acceptances or denials will be given to the applicant in writing. All Applications must be filed with final determinations.

Signature and Certification:

I certify that all information submitted in the application/pre screening process including the application, personal essay, resume, and any other supporting documentation is true. And in my own words and honestly presented. I understand that these documents and materials will become part of the CASAC program for which I am applying and will not be returned to me. Should any of the information be certified false, I may be subject to admission revocation and expulsion from the program.

Applicant Name: ______Signature:______

Reviewer Name: ______Signature:______

Date: ______

Final Determination: ______

Applications should be submitted to with a copy to