Skip to main content
Main navigation
Recertification
Application
Recertification FAQs
Requirements & Fees
Education Information
Auditing Information
Inactive & Emeritus Status
Certifications
Applications & Requirements
Verify A Credential
LPC Verification
Certified Peer Specialist
Certified Recovery Specialist
Certified Community Health Worker
Examinations
Information & Overview
Online Exams
Family-Based Therapy Exam
Retest Form
Test Taking Skills
Exam Prep for IC&RC Exams
Education
Search Education
CRS & CFRS Curriculum
Community Health Worker (CCHW)
Ethics
Codes of Ethics
Ethical Violations
Ethics FAQs
Guidelines for Filing a Complaint
Ethics Complaint Form
Self Report Form
Resources
Employment Opportunities
Letter of Good Standing Request
Expiration Date Change Form
Name Change Form
International Certificate
Reciprocity
Marketing Email Request Form
LPC Information
Login
First Name
Last Name
Email
Credential Number (if known)
Current Credentials
Certified Associate Addiction Counselor (CAAC)
Certified Alcohol and Drug Counselor (CADC)
Certified Advanced Alcohol and Drug Counselor (CAADC)
Certified Clinical Supervisor (CCS)
Certified Allied Addiction Practitioner (CAAP)
Associate Addiction Counselor (AAC)
Certified Prevention Specialist (CPS)
Certified Recovery Specialist (CRS)
Certificate of Competency in Problem Gambling (Gambling)
Certified Intervention Professional (CIP)
Certified Family Recovery Specialist (CFRS)
Certified Peer Specialist (CPS)
Certificate of Competency in Criminal Justice (CJ)
Certificate of Competency in Clinical Supervision (CS)
Certified Community Health Worker (CCHW)
Certified Recovery Specialist Supervisor (CRSS)
Certified Perinatal Doula
Date of Incident
The reason that you are self reporting
Were you arrested or received charges?
- Select -
Yes
No
Please provide us with the information that you would like the Board to know and take into account when reviewing this self-report
Submit