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First Name
Last Name
Email
Credential Number (if known)
Current Credentials
Certified Alcohol and Drug Counselor (CADC)
Certified Clinical Supervisor (CCS)
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Certified Peer Recovery Specialist (CPRS)
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Date of Incident
The reason that you are self reporting
Were you arrested or received charges?
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No
Please provide us with the information that you would like the Board to know and take into account when reviewing this self-report
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