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Application Forms

Board provided forms required for each certification or licensure:

As of November 1, 2016, only these forms will be accepted. Previous versions will be returned.

Consult the Administrative Rules for other requirements for licensure or certification.

* Review Forms may be used like checklists for the applications.

  1. All Licenses:
    1. Background Check Form pdf file
  2. Other Forms:
    1. Peer Collaboration Form  pdf file
  3. CRSW Applicants:
    1. CRSW – Initial Application Form pdf file (Alc 304.02)
    2. Exam Form and Cover Letter pdf file
    3. * CRSW Application Review Form  pdf file
  4. LADC Applicants (non-reciprocity based), and MLADC Applicants who do not currently hold a LADC license issued by the board:
    1. LADC & MLADC Initial Application Form pdf file
    2. LADC & MLADC Initial Application Form – Confidential Page pdf file
    3. LADC Written Case Study Form pdf file (Alc 308.03)
    4. Supervised Practical Training Report Form pdf file (Alc 313.05)
    5. Applicant Work Experience Report Form pdf file (Alc 313.06)
    6. Supervisor Work Experience Report Form pdf file (Alc 313.07)
    7. Employment Verification Form pdf file (Alc 313.08)
    8. Supervision Agreement pdf file (Alc 313.09)
    9. Counselor Evaluation Form pdf file (Alc 313.10)
    10. Professional Reference Form pdf file (Alc 313.11)
    11. LADC Educational and Training Summary Form pdf file (Alc 313.12)
    12. MLADC Educational and Training Summary Form  pdf file (Alc 313.12)
    13. Exam Form and Cover Letter pdf file
    14. LADC & MLADC Written Case Study Certification Form  pdf file
    15. * Case Study Review Form  pdf file
    16. * LADC & MLADC Application Review Form  pdf file
  5. LADC Applicants (reciprocity based pursuant to Alc 309):
    1. LADC & MLADC Initial Application Form pdf file
    2. LADC & MLADC Initial Application Form – Confidential Page pdf file 
    3. Supervisor Report Form for Reciprocity Applications pdf file (Alc 309.02), as needed pursuant to Alc 309.01(b)(11)
    4. * Reciprocity Application Review Form  pdf file
  6. MLADC Applicants who are currently licensed by the board as a LADC:
    1. LADC & MLADC Initial Application Form pdf file
    2. LADC & MLADC Initial Application Form – Confidential Page pdf file
    3. Supervised Practical Training Report Form pdf file (Alc 313.05)
    4. Applicant Work Experience Report Form pdf file (Alc 313.06)
    5. Supervisor Work Experience Report Form pdf file (Alc 313.07)
    6. Employment Verification Form pdf file (Alc 313.08)
    7. Supervision Agreement pdf file (Alc 313.09)
    8. Counselor Evaluation Form pdf file (Alc 313.10)
    9. Professional Reference Form pdf file (Alc 313.11)
    10. MLADC Educational and Training Summary Form pdf file (Alc 313.12)
    11. Exam Form and Cover Letter pdf file 
  7. MLADC Applicants (reciprocity based pursuant to Alc 312.01):
    1. LADC & MLADC Initial Application Form pdf file
    2. LADC & MLADC Initial Application Form – Confidential Page pdf file
    3. * Reciprocity Application Review Form  pdf file
  8. LCS Applicants:
    1. LCS Application pdf file (Alc 316.02)
    2. LCS Work Experience Report Form pdf file (Alc 316.05)
    3. LCS Clinical Supervision Training Form pdf file (Alc 316.06)
    4. Exam Form and Cover Letter pdf file
    5. * LCS Application Review Form  pdf file
  9. CEU Providers:
    1. Categories of Competence  pdf file
    2. Continuing Education Event Pre-Approval Form pdf file

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Office of Professional Licensure and Certification
121 South Fruit Street |  Concord, NH 03301
Main Telephone: (603) 271-2152