Licensed Chemical Dependency Counselor Program Applications and Forms

LCDC Application Intern and Reciprocity
Certified Clinical Supervisor Forms
CTI Application and Renewal Forms
CI Training and Supervision Forms for use by CTIs
LCDC Renewal Application

Obtain a copy of the following publications now - click on your selection.

Military Service Member, Veteran, or Military Spouse Supplemental Form

LCDC Application Forms

This application should be completed by all persons applying for registration as a Counselor Intern and to be eligible to test.

Application for Licensure by Exam/Internship (Counselor Intern Registration) (Word format, 36 KB)
Application for Licensure by Exam/Internship (Counselor Intern Registration) (Adobe Acrobat format, 446 KB)

This application should be completed by all persons applying for licensure as a Licensed Chemical Dependency Counselor on the basis of a current out-of-state license.

Application for Licensure by Reciprocity (Word format, 33 KB)
Application for Licensure by Reciprocity (Adobe Acrobat format, 367 KB)

LCDC Renewal Form

Renewal applications will not be accepted more than 60 days prior to your expiration date.

LCDC Renewal Form (Word format,  44 KB)
LCDC Renewal Form (Adobe Acrobat format, 356 KB)

CTI Application and Renewal Forms

Clinical Training Institution (CTI) Application Form (Word format, 32 KB)
Clinical Training Institution (CTI) Application Form (Adobe Acrobat format, 337 KB)

Submit this form to renew your CTI registration.

Clinical Training Institution (CTI) Observation Documentation Form (Word format, 30 KB)
Clinical Training Institution (CTI) Observation Documentation Form (Adobe Acrobat format, 18 KB)

CI Training and Supervision Forms for use by CTIs

Supervised Work Experience Documentation Form (Word format, 36 KB)
Supervised Work Experience Documentation Form (Adobe Acrobat format, 374 KB)

CTI Intern Assessment Form (Word format, 28 KB)
CTI Intern Assessment Form (Adobe Acrobat format, 17 KB)

CTI Intern File Checklist (Word format, 29 KB)
CTI Intern File Checklist (Adobe Acrobat format, 19 KB)

Counselor Intern Evaluation Packet (Word format, 80 KB)
Counselor Intern Evaluation Packet (Adobe Acrobat format, 501 KB)
(This packet includes the quarterly evaluation form, intern specific personal contract, and weekly documentation of hours.)

To access documents in Adobe Acrobat format, you must download the Acrobat Reader software. Please see the DSHS file viewing page for more information and a link to the Adobe website.

 

Last updated August 31, 2017