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First Name
Last Name
Email
Credential Number (if known)
Current Credentials
Certified Alcohol and Drug Counselor (CADC)
Certified Advanced Alcohol and Drug Counselor (CAADC)
Certified Clinical Supervisor (CCS)
Provisional Alcohol and Drug Counselor (PADC)
Certified Prevention Specialist (CPS)
Associate Prevention Specialist (APS)
Certified Peer Recovery Specialist (CPRS)
Problem Gambling Endorsement
Certified Community Health Worker (CCHW)
Advanced Prevention Specialist (ACPS)
Student Assistance Counselor (SAC)
Human Immunodeficiency Virus (HIV) Endorsement
Cardiovascular Health and Diabetes Endorsement
Older Adults Endorsement
Certified Perinatal Doula (CPD)
Competency in Supporting Children and Individuals with Special Needs and Their Families
Certificate of Competency in Perinatal Mental Health
Mental Health and Substance Use Disorder Endorsement
Date of Incident
The reason that you are self reporting
Were you arrested or received charges?
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Yes
No
Please provide us with the information that you would like the Board to know and take into account when reviewing this self-report
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