Alc/Drug Counselor -- 360 Hours Ed Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
ALCOHOL AND DRUG COUNSELOR LICENSURE / CERTIFICATION VERIFICATION OF EDUCATION
TO BE COMPLETED BY APPLICANT

Applicant: Please complete the top portion of this form and forward to the appropriate authority for official verification of completion of education in alcohol and drug counseling.
Name of Applicant*
First and Last Name
Year of Completion *
Year of Completion
Identification information (i.e. social security number) if required by verifying entity*
Identification Information
INFORMATION BELOW TO BE COMPLETED BY VERIFYING AUTHORITY ONLY

Section 1. The applicant listed above is applying for licensure/certification as an alcohol and drug counselor in Connecticut. Please provide the following information regarding the course of study that such individual completed at your institution.
Title of training
Title of Training
YesNo
Where was such instruction completed?
Name of School or Training Provider
Dates of attendance: from

MonthDayYear
To

MonthDayYear
Section 2. To qualify for licensure or certification this individual must have completed 360 hours of education, at least 240 of which pertained to alcohol and drug abuse, while the remaining hours must have been in the field of human behavior.
YesNo
If no, number of hours completed
Number of Hours
YesNo
If no, number of hours completed
Number of Hours

Did this individual complete the following areas and minimum hours related to alcohol and drug abuse:

Rows	Yes	No	If No, number of hours completed.
Pharmacology – 18 hours
assessment and treatment planning – 30 hours
cross-cultural, special population and ethnically diverse groups 12 hours
ethics – 12 hours
HIV – AIDS – 6 hours

If any of the above areas were not satisfied, please elaborate:
Add any details not covered above.
Note: In responding to this section, no more than 40 hours of inservice training may be credited toward satisfying the educational requirements.
Screeningintakeorientationassessmentcounselingreferralcase managementconsultationtreatment planningcrisis interventionclient educationreport and record keeping
Name and Title of Person Completing Form

First and Last NameTitle
Institution
Institution
Signature of Authorized Representative
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date

MonthDayYear
Daytime Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Thank you for your assistance. Please return this form directly to:

Department of Public Health
ADC Licensure/Certification
410 Capitol Ave., MS #12APP
P.O. Box 340308
Hartford, CT 06134-0308
Should be Empty: