Student Interest Form

    

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
Main telephone number
Other telephone number
Street Address
City
State
Zip Code
Why do you want to take drug and alcohol counseling courses?
Describe your experience, if any, in the field substance abuse counseling or helping others.
At which location will you do the practicum?
Use this space for your questions or comments.
Check if you are 18 or over.
 

 

 

 

  
 
 
 
 
 
 
 
 
   
 
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