Update form for Treatment Counselors Seeking a Degree

 

Please complete the following form.

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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

 

 

 

Financial info

Number in your household: (Include yourself, spouse and children.)
Currently employed:   Yes   No
  Name of employer:
Will you continue to work while enrolled in college: Yes     No
Income, Earnings, and Benefits
 
 
Household
You
Income earned last year
Federal income tax paid
NC income tax paid
Total number of exemptions
Assets Information
  Cash, savings and checking accounts total:
Monthly expenses
 
mortgage payment
rent
food
utilities
credit cards
car loans
other
total
Financial Aid
 
  Amount Sources
Federal loan (source, if known)
other loan(s)  
Pell grant  
VA support  
other grants/stipends (list sources)

Comments:

 

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