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Board of Licensing for Alcohol and Other Drug Use Professionals Application Forms

Board provided resources, documents and other forms required for each certification or licensure.

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Resources

Other Forms

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. Criminal Record Release Authorization Form Fingerprinting Required
    2. Military Service Question
  2. Other Forms:
    1. Peer Collaboration Form
    2. Medicaid-to-Schools Questionnaire
  3. CRSW Applicants:
    1. CRSW – Initial Application Form (Alc 304.02)
    2. Exam Form and Cover Letter
    3. CRSW Application Review Form *
  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
    2. LADC & MLADC Initial Application Form – Confidential Page
    3. LADC Written Case Study Form (Alc 308.03)
    4. Supervised Practical Training Report Form (Alc 313.05)
    5. Applicant Work Experience Report Form (Alc 313.06)
    6. Supervisor Work Experience Report Form (Alc 313.07)
    7. Employment Verification Form (Alc 313.08)
    8. Supervision Agreement (Alc 313.09)
    9. Counselor Evaluation Form (Alc 313.10)
    10. Professional Reference Form (Alc 313.11)
    11. LADC Educational and Training Summary Form (Alc 313.12)
    12. MLADC Educational and Training Summary Form (Alc 313.12)
    13. Exam Form and Cover Letter
    14. LADC & MLADC Written Case Study Certification Form
    15. Case Study Review Form
    16. LADC & MLADC Application Review Form
  5. LADC Applicants (reciprocity based pursuant to Alc 309):
    1. LADC & MLADC Initial Application Form
    2. LADC & MLADC Initial Application Form – Confidential Page
    3. Supervisor Report Form for Reciprocity Applications (Alc 309.02), as needed pursuant to Alc 309.01(b)(11)
    4. Reciprocity Application Review Form *
  6. MLADC Applicants who are currently licensed by the board as a LADC:
    1. LADC & MLADC Initial Application Form
    2. LADC & MLADC Initial Application Form – Confidential Page
    3. Supervised Practical Training Report Form Alc 313.05)
    4. Applicant Work Experience Report Form (Alc 313.06)
    5. Supervisor Work Experience Report Form& Alc 313.07)
    6. Employment Verification Form (Alc 313.08)
    7. Supervision Agreement (Alc 313.09)
    8. Counselor Evaluation Form (Alc 313.10)
    9. Professional Reference Form (Alc 313.11)
    10. MLADC Educational and Training Summary Form (Alc 313.12)
    11. Exam Form and Cover Letter
  7. MLADC Applicants (reciprocity based pursuant to Alc 312.01):
    1. LADC & MLADC Initial Application Form
    2. LADC & MLADC Initial Application Form – Confidential Page
    3. Reciprocity Application Review Form
  8. LCS Applicants:
    1. LCS Application (Alc 316.02)
    2. LCS Work Experience Report Form (Alc 316.05)
    3. LCS Clinical Supervision Training Form (Alc 316.06)
    4. Exam Form and Cover Letter
    5. LCS Application Review Form *
  9. CEU Providers:
    1. Categories of Competence
    2. Continuing Education Event Pre-Approval Form
  10. Reinstatement:
    1. Reinstatement Application for CRSW

     

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