Substance Abuse Counselor: Education Verification

Public Health: Alcohol And Drug Counselor Licensure/Certification - Verification Of Education

DPH Data Management and Governance (PLIS)
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:
Year of Completion:
Identification information (i.e. social security number) if required by verifying entity :
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:
Did this training pertain to alcohol and drug abuse?
Where was such instruction completed?
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. Did this individual satisfy these hourly requirements?
If no, number of hours completed:
Did this individual complete at least 90 hours in counseling theories and techniques?
If no, number of hours completed:

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:
Note: In responding to this section, no more than 40 hours of inservice training may be credited toward satisfying the educational requirements.
Please indicate whether the following core counseling functions were represented in this applicant’s education:
Name of Person Completing Form:
Title of Person Completing Form:
Institution:
Day Time Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Authorized Representative:
Date:

MonthDayYear
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:

Public Health: Alcohol And Drug Counselor Licensure/Certification - Verification Of Education