Student Interest Form for Hybrid Courses

    

Please fill out the form below carefully. This starts your screening process. After submitting the form, a CI representative will contact you within one business day. Please make sure your telephone number and email address are correct.

First Name
Last Name
email address
Retype email address
Telephone number
Other telephone number
Street Address
City
State
Zip Code
Describe your experience in the field of drug and alcohol counseling, particularly years of experience.
Why do you want to take the drug and alcohol counseling courses?
State the site where you will do your practicum (internship). If you don't know yet, state that you don't know.
Comments
Check if 18 or over
Which time are you interested in taking the courses?
 Friday Evenings Saturdays
Click the button to submit your form.
 

 

 

 

  
 
 
 
 
 
 
 
 
   
 
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