AIS Membership Application

Below is the digital application, please read the form ahead of time and ensure you have all your documentation

The form will not save your data and once you submit the data it will email us directly. At the bottom of this initial form it is imperative you digitally sign before moving on to the next step.

Please check which you are applying for

RADIO: Please check which you are applying for?

Full (Certified Intervention Professional (CIP) Certification and/or Canadian Certified Intervention Professional (CCIP) is Required for Full Membership) Candidate Associate Emeritus

Please choose from below

Radio:Please choose from below

Certified Intervention Professional (CIP) Canadian Certified Intervention Professional (CCIP) None

CIP or CCIP Number

Applicant Information

Name*

Company

Current Address*

City*

State/Providence*

Zip/Postal Code

Phone Number

Email*

Work Experience Related to Interventions: (Where have you worked, when, what duties did you perform....)

Training and/or educational experiences related to Interventions

Style of Intervention (brief statement of philosophy)

Types of interventions offered – (AOD, Eating Disorders, Sexual Trauma, Gambling, etc....)

Geographical Locations (areas where you will facilitate interventions)

Other Services Offered

Credentials (Degrees, Licenses, certifications including first year received)

AIS Membership Application

References

Name*

Address*

Phone*

Personal Statement*

Verification

Digital Signature of Applicant: *

Name*

I authorize the verification of the information provided on this form as to my credit and employment.

Date*

Step 1: Almost Completed

By submitting the above information, I am submitting my application for consideration as a member of AIS.

AIS Code of Ethics

Below is the AIS Code of Ethics. We ask they you review each and every Principal and Rules of Conduct.

At the end of this page you MUST Digitally sign that you authorize and have read and understand the Code of Ethics and Rules of Conduct.

Mission: To provide leadership in the profession of behavioral health intervention All members adhere to the AIS Code of Ethics as reproduced below:

PRINCIPLE 1: Non discrimination

The intervention specialist must not discriminate against clients, organizations, or other professionals based on race, religion, color, age, sex, sexual orientation, mental or physical handicap, national origin or economic condition.

PRINCIPLE 2: Competence

The intervention specialist must recognize that this profession is founded on standards of competence, which promotes the best interest of the client, the intervention specialist, this profession, and society. The intervention specialist must accept the need for ongoing education as an integral part of professional competence. The intervention specialist must recognize the boundaries and limitations of one’s own competencies, and not offer services or use techniques outside of these professional competencies. The intervention specialist must recognize the effect of physical and mental impairment on professional performance, and be willing to seek appropriate treatment for oneself or for a colleague.

PRINCIPLE 3: Legal and Ethical Standards

The intervention specialist must uphold the legal and accepted ethical codes, which pertain to professional conduct. The intervention specialist must not use the affiliation with the Association of Intervention Specialists for purposes that are not consistent with the stated mission of the Association.* * The intervention specialist who is aware of unethical or illegal professional conduct must report such violations to the appropriate certifying authority.

PRINCIPLE 4: Client Welfare

The intervention specialist must respect the integrity and protect the welfare of the person or group with whom the specialist is working. The intervention specialist must assume the responsibility for clients’ welfare either by termination by mutual agreement and/or by the client becoming engaged with another professional.

PRINCIPLE 5: Confidentiality

The intervention specialist must embrace, as a primary obligation, the privacy of clients and must not disclose confidential information acquired in teaching, clinical practice, training or consultation sessions, except when there is a clear and imminent danger to client or other persons.

PRINCIPLE 6: Societal Obligations

The intervention specialist must adopt a personal and professional stance, which promotes the well being of all human beings. The intervention specialist must inform the public through active civic and professional participation in community affairs of the effect of addiction, and must act to guarantee all persons, especially the needy and disadvantaged, have access to necessary resources and services.

PRINCIPLE 7: Remuneration

The intervention specialist must establish arrangements in professional practice, which are in accord with the professional standards that safeguard the best interest of the client, the specialist and the profession. The intervention specialist may not exploit relationships with clients or patients for personal advantage or satisfaction. The intervention specialist will not accept direct enumeration for making or receiving a referral of a patient.

Verification

Digital Signature of Applicant: *

Name*

I authorize that I have read and understand the Code of Ethics and Rules of Conduct.

Date*