Recertification Application

Biographical Data






For statistical purposes only


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Select Certification to recert


Continuing Education (40 Hours)

5 Hours of Ethics and 3 hours of Telemental Healthare required for each recertification period.

20 Hours for CADC-T

All continuing education hours must be recorded below. Any certificates unlisted will be rejected.

No. Title Dates Topic
(12 Core Concepts)
Hours CE Provider
(i.e., ADACBGA,
GACA, LPC, Etc.)


Please attach copies of certifications, transcripts, or reports of inservice hours. Combine all files to PDF or ZIP.

ASSURANCE AND RELEASE

ETHICS STATEMENT

(Please Check Where Requested as Indication You Have Read and Understand Each Section)


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