Update form for Treatment Counselors Seeking Certification

 

Please complete the following form.

(No ID? Apply now or contact us)
First Name:
Last Name:
Home Address:
City/Sate/Zip:
     
Date of Birth
SSN# last 4 digits
Phone:
 (home) (fax)
(work) (ext)
e-Mail:
Current Occupation
Employer
Supervisor's Name and Title
Employer's Address
Sex
 Male     Female

Race/Ethnicity* Highest Level of Education
African American High School Diploma
Hispanic American G.E.D.
Caucasian AA Degree/Diploma
Native American Some College or Technical/Trade School
Asian/Pacific American Bachelor's Degree. Major:
Other: Advanced Degree. Specify:
*For outreach and recruitment efforts

If currently enrolled, enter

Name of school:

Degree sought:

 

Requirements Completed for Substance Abuse Counselor Certification
Obtained certification package. Date:
Registered with the NC Substance Abuse Professional Practice Board (formerly NC Substance Abuse Professional Certification Board)
Years of full time or volunteer supervised substance abuse counseling experience
Hours of board approved education/training
Written exam passed/scheduled to take. Date:
Certified in North Carolina. Type: CSAC   LCAS   CCS
Working towards NC Certification. Type: CSAC   LCAS   CCS

 

 

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