CE Provider Submission – Alcohol & Drug Abuse Certification Board of Georgia

Continuing Education Provider Application Form

If you have reviewed the ADACBGA’s Educational Provider Standards and wish to apply for approval as a Continuing Education Provider, please complete the below form.

Along with the submission of this form, you must upload a PDF file that includes a listing of the following related to ALL courses for which you are seeking approval:

Course/Workshop Title(s)
Date(s) each Course(s)/Workshop(s) are being offered
Location of the Course(s)/Workshop(s)
Approved Format of the Course(s)/Workshop(s):
- face-to-face in-person
- live face-to-face videoconference, or
- asynchronous interactive
Not less than three (3) measurable objectives for each Course/Workshop related to the 12 Core Functions of the A&D Counselor, Professional & Ethical Responsibilities, or the Performance Domains of the Clinical Supervisor, or Peer Recovery Specialist, depending on the topic of the Workshop.
A short narrative description for each Course/Workshop.
The full name, contact information, and credentials of each presenter/instructor.
A current, up-to-date Curriculum Vitae for each presenter/instructor.
If an asynchronous course offering, a description of how the course will be interactive and the presenter/instructor available for questions before, during, and/or after the Course/Workshop should be included.
- Asynchronous interactive course(s)/workshop(s) must include a scored, competency-based evaluation/quiz after the completion of the training in addition to the overall workshop evaluation.

Provider (Individual or Organization) *Please enter the name of the provider

Course/Event Title *Please enter the course/event title

Contact Email Address *Please enter the contact email address

Provider Phone Number *Please enter the provider phone number

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Provider Website

Course/Event information

Upload CE Application Requirement Files for Review

Course description(s), objective(s), schedule, CVs of presenter(s), etc.

Would you like this listed on our website under approved CE providers? *YesNo

Number of hours1-14 Hours One presentation1- 14 Hours Multiple presentations of Single Topic15 hours or more One presentation15 hours or more Multiple Presentations of Single TopicSingle Presentation of Multiple TopicsMultiple Presentations of Multiple Topics

Fee

Credit / Debit Card *

Allow for up to 30 days for review of CE Provider Applications. By submitting this application you acknowledge that application Fees are non-refundable and non-transfereable.

By submitting this CE Provider Application, I attest that I have reviewed and will ensure compliance with the ADACBGA’s standards for educational providers detailed on and/or linked to this page. I understand failure to maintain these standards will result in loss of CE approval status and could open me up to ethical sanctions.