Fillable Printable Lcdc Ii Certification Application
Fillable Printable Lcdc Ii Certification Application
Lcdc Ii Certification Application
LICENSED CHEMICAL DEPENDENCY COUNSELOR II
FORMAL APPLICATION
This application must be returned to the Chemical Dependency Professionals Board. It will not be considered
complete until all related documents, transcripts, reference forms and fees have been received by the Board.
Applicant and supervisor answers should be full and complete. Vague and/or incomplete applications will be
returned, causing a delay in the application process. Intentionally false and/or misleading statements may result
in denial or revocation of certification.
Please type or print legibly.
Applicant Name (first, middle and last)
Maiden Name (if applicable)
Date of Birth
SS #
- -
Preferred Mailing Address (Please provide street number, street name, city, state and zip.)
County
Home Phone
/
-
Work Phone
/
-
Mobile Phone
/
-
FAX #
/
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E-Mail Address
Would you like to receive correspondences regarding your application via email?
Yes
No
I. PERSONAL HISTORY INFORMATION
Have you ever had a professional license/certificate reprimanded, suspended,
revoked, surrendered or in any other way sanctioned? If yes, please attach a
written explanation.
Yes
No
Have you ever been convicted of a felony? If yes, please complete the felony
questionnaire
Yes
No
Do you currently live or work at least 51% of the time in Ohio?
Yes
No
page 1
page 2
II. CHEMICAL DEPENDENCY COUNSELING WORK EXPERIENCE
Supervisor references are required as part of this application. The supervisor reference form must provide at
least three years (6,000 hours) of knowledge of the applicant’s chemical dependency counseling work
experience. An associate’s degree in a behavioral science may be substituted for 6 months of work
experience, a bachelor’s degree in a behavioral science may be substituted for one year of work experience,
a master’s degree o r higher in a behavioral science may be substituted for two years of work experience.
One year of full time work experience equals 2,000 hours.
Additionally, a verification of tasks form must be completed documenting a minimum of 330 practical
experience hours in the 12 core functions. If there was more than one supervisor during these times, forms
should be duplicated so that each may have an appropriate form to complete. Completed reference forms
and verification of tasks forms must be returned with this application.
Please record your chemical dependency counseling work experience below. To meet the Chemical
Dependency Professionals Board work experience requirements, a minimum 20 percent of employment
must have been spent in the counseling portion of the 12 core functions as it relates to the alcohol and/or
other drug-addicted client. Final determ ination of the acceptability of work experience shall be at the
discretion of the Board. Duplicate this page as needed to account for the required minimum amount of work
experience. Your supervisor-signed job description(s) covering this time must be included with this
application. Please list most recent experience first.
Employer: ____________________________________________________________________________
Name and Title of Supervisor: ____________________________________________________________
Length of Employment (month and year): From ____________________ To ______________________
Job Title: ________________________________________ Number of hrs worked per week: ________
Employer: ____________________________________________________________________________
Name and Title of Supervisor: ____________________________________________________________
Length of Employment (month and year): From ____________________ To ______________________
Job Title: ________________________________________ Number of hrs worked per week: ________
Employer: ____________________________________________________________________________
Name and Title of Supervisor: ____________________________________________________________
Length of Employment (month and year): From ____________________ To ______________________
Job Title: ________________________________________ Number of hrs worked per week: ________
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III. FORMAL ACADEMIC EDUCATION
Applicants must hold at least an associate’s degree in a behavioral science or a bachelor’s degree in any
field. Enter all requested information for each institution you list. A transcript from each must be included
with this application. Please list in order, starting with the most recently attended institution.
Institution: ___________________________________________________________________________
Dates Attended: From _______________ To _______________ Total Hours Earned: ___________
Major or Core of Study: ________________________________________________________________
Degree Awarded: ______________________________ Date Degree Awarded: ___________________
Institution: ___________________________________________________________________________
Dates Attended: From _______________ To _______________ Total Hours Earned: ___________
Major or Core of Study: ________________________________________________________________
Degree Awarded: ______________________________ Date Degree Awarded: ___________________
Institution: ___________________________________________________________________________
Dates Attended: From _______________ To _______________ Total Hours Earned: ___________
Major or Core of Study: ________________________________________________________________
Degree Awarded: ______________________________ Date Degree Awarded: ___________________
Institution: ___________________________________________________________________________
Dates Attended: From _______________ To _______________ Total Hours Earned: ___________
Major or Core of Study: ________________________________________________________________
Degree Awarded: ______________________________ Date Degree Awarded: ___________________
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IV. APPLICANT STATEMENT FOR NOTARIZATION
I hereby affirm that I am of good moral character and that all information given herein is true and complete to the best of
my knowledge and belief. I authorize any necessary investigations and/or release of personal information to the Chemical
Dependency Professionals Board and its agents. I understand that falsification of any portion of this application may result
in my being denied certification/licensure or in revocation of the same.
I hereby affirm that I have read the Chemical Dependency Code of Ethics, and I agree to abide by this code. (The Chemical
Dependency Code of Ethi cs may be accessed at
www.ocdp.ohio.gov or may b e sent to an individual upon request.)
I further agree to hold the Chemical Dependency Professionals Board free from any civil liability for damages or
complaints related to any action within the scope and/or arising out of the performance of its duties, which it or any of its
employees may take in connection with this application and/or failure to issue me said license.
I understand that the $50 fee submitted herewith represents the non-refundable LCDC II Formal Application fee. (A non-
refundable $20 fee will be charged for any check not accepted for deposit by the bank.)
________________________________________________ ________________________
Applicant Signature Date
Subscribed and sworn before me this ___________ day of _____________________, 20______
________________________________________________ ________________________
Notary Signature Date Commission Expires
If paying via check or money order:
All checks and money orders should be made payable to “Treasurer, State of Ohio.”
Please return completed application, including required documentation and fee, to:
Ohio Chemical Dependency Professionals Board
77 South High Street, 16
th
Floor Columbus, Ohio 43215
614/387-1110 (phone) 614/387-1109 (fax)
www.ocdp.ohio.gov
Email:
credentialing@ocdp.state.oh.us
FOR OFFICE USE ONLY
Date Received: Fee Paid: Check/M.O./C.C. #:
Last Updated 06/10
Credit Card Payment Authorization Form
Please check one:
Master Card
Visa
Cardholder Name:
Address:
City, State, Zip:
Telephone #:
Email Address (for receipt)
Credit Card Number:
Expiration Date:
CVV2/CID Code # (Three digit number on back of card):
Payment Amount:
Payment for (exam, application, etc):
Signature Date
Credit Card Payments may be mailed, faxed, emailed, or phoned in to the Board office.
Ohio Chemical Dependency Professionals Board
77 South High Street, 16
th
Floor Columbus, Ohio 43215
614/387-1110 (phone) 614/387-1109 (fax)
www.ocdp.ohio.gov
Email: [email protected]
This document will be shredded after your payment is processed.
LICENSED CHEMICAL DEPENDENCY COUNSELOR II
FORMAL APPLICATION CHECKLIST
To facilitate the review of your LCDC II formal application and to avoid unnecessary delays
in processing, please use the following checklist when completing the application. All items
on this checklist must be included for your formal application to be complete and acceptable
to the Board. Incomplete or inappropriately completed applications will be returned and will
result in a delay of processing.
Check each item when completed:
_____ Application is complete, signed and notarized
_____ $50.00 application fee enclosed. All fees should be made payable to
Treasurer, State of Ohio.
_____ Felony question has been answered. If you have been previously
convicted of a felony, you will need to complete a felony questionnaire
and submit it with your formal application.
_____ Supervisor Reference Form enclosed.
_____ A job description, signed by your supervisor, has been enclosed with
this application.
_____ Verification of Tasks Form completed documenting 330 practical
experience hours in the 12 core functions.
_____ Completion of Education Grid and verification of education hours in the
form of transcripts, certificates and/or letters of completion have been
submitted with this application.
_____ Verification of completion of at least an Associate’s degree in a
behavioral science or a non-related Bachelor’s degree.
All forms are available at
www.ocdp.ohio.gov or by calling (614) 387-1110.
Last Updated 9/07
