Fillable Criteria for Certified Reciprocal Alcohol & Drug Counselor (Missouri Credentialing Board)

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Criteria for Certified Reciprocal Alcohol & Drug Counselor (Missouri Credentialing Board)

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Revised August 2019 CRADC (ADC) Application
1
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Criteria for Certified Reciprocal Alcohol & Drug
Counselor (CRADC)
I. Criteria for those with an applicable Masters Degree
Applicable Masters Degree
2000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Competency Rating Form from MCB qualified supervisor
300 Contact Hours of Education to include the following:
• 6 live ethics hours (not from online or home study)
• 20 of the 300 hours obtained within the prior 12 months of applying
Pass IC&RC International ADC Examination if not upgrading from CADC
II. Criteria for those with an applicable Bachelors Degree
Applicable Bachelors Degree
4000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Competency Rating Form from MCB qualified supervisor
300 Contact Hours of Education to include the following:
• 6 live ethics hours (not from online or home study)
• 20 of the 300 hours obtained within the prior 12 months of applying
Pass IC&RC International ADC Examination if not upgrading from CADC
III. Criteria for those with an applicable Associates Degree
Applicable Associates Degree
5000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Competency Rating Form from MCB qualified supervisor
300 Contact Hours of Education to include the following:
• 6 live ethics hours (not from online or home study)
• 20 of the 300 hours obtained within the prior 12 months of applying
Pass IC&RC International ADC Examination if not upgrading from CADC
Criteria continued on next page
Revised August 2019 CRADC (ADC) Application
2
IV. Criteria for those with a High School Diploma/HSE
High School Diploma/HSE
6000 hours of applicable work experience within the last 10 years
300 hours of a Supervised Practicum in the Performance Domains
Signed Competency Rating Form from MCB qualified supervisor
300 Contact Hours of Education to include the following:
• 6 live ethics hours (not from online or home study)
• 20 of the 300 hours obtained within the prior 12 months of applying
Pass IC&RC International ADC Examination if not upgrading from CADC
APPLICABLE DEGREES
(A degree must be from a college or university found in the US Dept. of Education’s database of accredited
schools. The database can be found at http://ope.ed.gov/accreditation.)
1. Psychology 6. Sociology 10. Human Services
2. Social Work 7. Chemical Dependency 11. Art Therapy
3. Criminal Justice 8. Counseling 12. Applied Behavioral Science
4. Family Studies 9. Nursing 13. Education
5. Communication
* If your Related Field Degree (Major) is in one of the above areas but has a different transcript title, please
contact the MCB office at 573-616-2300 to verify it will be accepted as an applicable degree.
Revised August 2019 CRADC (ADC) Application
3
DEFINITIONS
A. CONTACT HOURS of EDUCATION/TRAINING is defined as workshops, seminars, institutes,
accredited college/university courses, MCB approved home study or on-line courses and in-services. One (1)
contact hour of education is equal to sixty (60) minutes of continuous instruction. 15 contact hours are given
for each college credit. Therefore, a college course of three (3) credits is equal to 45 contact hours.
In order to be considered a valid training experience for the purpose of credentialing, education/trainings must
be related to the knowledge and skill base associated with the performance domains of a substance use disorders
counselor.
All education taking place outside the applicant's place of employment must be documented through proof of
attendance including transcripts from an accredited college, letters and/or certificates of completion.
Supporting documentation in the form of brochures, flyers, syllabus, course description, etc. may also be
required to review content for acceptability.
All education taking place within the applicant's place of employment must be documented by title, date and
length of presentation, as well as the name and title of presenter. The training must be verified by the
employee's supervisor who attests the training took place and the employee was a participant in the entire
training.
B. APPLICABLE WORK EXPERIENCE is defined as supervised work experience in a position with job
duties that assist clients in the recovery process by performing the substance use disorder counselor
performance domains. Experience as a volunteer, intern and/or payment of a stipend qualifies as work
experience if the same work is performed that a paid employee would perform.
All qualifying work experience must have been accrued during the ten (10) years immediately prior to
application being made.
Work experience must be verified by an employment verification form from the agency(s) in which the
applicant has been employed.
C. SUPERVISED PRACTICUM IN THE PERFORMANCE DOMAINS is defined as performance of
the performance domains while under supervision.
Supervision must be provided by someone who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC,
RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has attended the MCB Clinical Supervision
Training.
The supervision of the performance domains may take place within an academic setting and/or within a
supervised work setting. The goal is to receive supervised experience in all of the domains. Applicants must
complete a minimum of 10 hours performing each of the domains with a total supervised practicum of 300
hours.
D. PERFORMANCE DOMAINS DEFINITIONS: Refer to the ADC Candidate Guide on the MCB web
site at www.missouricb.com under the Education Box/Candidate Guide link.
Revised August 2019 CRADC (ADC) Application
4
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
CHECK LIST FOR CRADC APPLICATION
1. You have submitted the $400.00 with this application if you are a new applicant, $325.00 if you are
upgrading from a MAADC I/II, or $125.00 if you are upgrading from a CADC.
2. You have paid by check or money order, or have provided your credit/debit card information on page 8
of this application packet. Applications will not be reviewed until payment is received.
3. You have completely filled out the application.
4. You have signed the Code of Ethical Practice and Professional Conduct.
5. You have filled out the Family Care Safety Registry Worker Registration Form and included the form
with your packet. If your agency has conducted a FCSR background check on you within the last 30
days, you may submit the results to help expedite the application process.
6. You have submitted proof of 300 total hours of education/training with 20 of those hours being
obtained within the 12 months prior to application.
7. The appropriate person has completed and signed the Counselor Employment Verification Form(s) and
you have included the completed form with your application.
8. If necessary, the Supervised Practicum Form was filled out by a MCB qualified supervisor and you have
included the completed form with your application.
9. The Competency Rating Form was filled out by a MCB qualified supervisor and you have included the
completed form with your application.
10. The appropriate High School/HSE or College transcripts were sent.
11. Typically, applications are reviewed within two weeks of receipt in the MCB office. If you have not
received written correspondence from the MCB 3 weeks after mailing your application to the MCB, call
the MCB
12. If you took and passed the examination and you have not received correspondence from the MCB, check
the Professional Search on the MCB web site homepage at www.missouricb.com. Type in your last
name. If your application is complete, your credential information will be displayed and you should
have received your welcome letter and certificates by e-mail.
Revised August 2019 CRADC (ADC) Application
5
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Application Instructions:
1. Requirements to receive this credential are subject to change without notice. Please make sure you are
submitting the most recent application packet. If you are unsure, contact the MCB office.
2. The application must be typed or neatly printed.
3. Please keep a copy of all materials submitted for your records.
4. FEES: The total CRADC Fee for a new applicant is $400.00. The total CRADC Fee for someone
upgrading from a MAADC I/II is $325.00. The total CRADC Fee for someone upgrading from a CADC
is $125.00. You may pay by check, money order, or by providing credit card information on page 8 of
this application packet. Applications will not be reviewed until payment is received.
5. Please be advised that should your application be reviewed and additional information is requested, you
will have 90 days to provide the requested information. Failure to do so will result in your application
expiring without being approved.
6. All fees are non refundable. If your application is denied or expires, fees will not be refunded.
7. If your application is denied, you may contact the MCB office staff for instructions on how to appeal the
denial of your application.
8. All materials submitted to the MCB office become property of the MCB.
9. The applicant must currently reside and/or be employed in the State of Missouri at least 51% of the time.
The only exception to this is applicants living and working in a state that is not a member of the
International Certification and Reciprocity Consortium.
10. Please remember that it is your responsibility to keep the MCB office informed of any personal
informational changes such as address and phone number changes. If you fail to notify us of changes,
you will be responsible for any material that is mailed to the wrong address and will have to pay a fee to
have the material sent again.
11. Please mail your application to the MCB. Please do not fax or e-mail your application.
Special Instructions For Those Applicants Upgrading
1. Your application is a continuation from your previous application(s). Therefore, you do not need to
submit duplicate information from previous applications such as transcripts, training certificates sent
with previous applications, etc. However, you must completely fill out the application packet.
Revised August 2019 CRADC (ADC) Application
6
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Useful Information:
1. If at any time during the application process, a question arises about an applicant’s moral character,
reputation for honesty, integrity, or professionalism, the Board may either deny the application at that
time or place the application on hold until an investigation has been done and a decision made regarding
the question brought up.
2. Once your application has been accepted and has final approval, you will receive an e-mail and/or letter
from our office with further instructions on how to continue the application/testing process. With this
letter, you will also receive information on obtaining a free Candidate Guide. This guide provides you
sample questions for the exam. In addition, additional study materials can be purchased. The companies
that sell study guides are listed on our web site www.missouricb.com under the “Education Box/Study
Guide Information” link. The exam you are taking is called the ADC Exam.
3. The CRADC credential is a reciprocal credential with other IC&RC member boards that offer this
credential. You can contact the MCB office for more information on reciprocity.
Revised August 2019 CRADC (ADC) Application
7
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to those
seeking a MCB credential.
1. No individual currently under any type of court supervision can apply for a MCB credential. Please
wait until you are completely free from court supervision before applying.
2. The following items disqualify an individual from ever being credentialed with the MCB:
A. Is listed on the Department of Mental Health disqualification registry
B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept. of
Social Services
C. Any crime against a minor
D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of
the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only disqualify
an applicant if the crime (s) were a felony. Please view information about Section 630.170, RSMo
on the MCB web site www.missouricb.com under the Disqualifying Crimes Link.
3. If an individual has applied for and been given an exception from the Department of Mental Health, the
individual may apply for a MCB credential. Please send in proof of exception with your application.
Revised August 2019 CRADC (ADC) Application
8
APPLICATION
FOR
Certified Reciprocal Alcohol & Drug Counselor
(CRADC)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 2
nd
Floor
JEFFERSON CITY, MISSOURI 65101
TELEPHONE: (573) 616-2300
WEB SITE: www.missouricb.com
EMAIL: help@missouricb.com
Please Mark Credit Card Type:
1. Visa _____________
2. MC _____________
3. Discover _____________
CC Expiration Date: _____/_______
Credit Card #: __________-______________-______________-____________
Credit Card 3 Digit Verification Code: ________________________________
Revised August 2019 CRADC (ADC) Application
9
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Please check if you are: ______ New Applicant ______ Upgrade Applicant
Applicant’s Name: ___________________________________________________________________________
First Middle Last Name Suffix (Jr., II)
___________________________________________________________________________________________________________
Maiden Other Names Used
Current Home Address: _____________________________________________________________________________
Street/PO Box Apt. #
______________________________________________________________________________________________________________________
City State Zip County
Home Telephone: ________/_______________ SSN: __________-________-______________
Work Telephone:
________/_______________, Ext. ________ Cell Number: ________/_______________
E-mail Address:
_____________________________________________________________________________
SEX: ____M ____F BIRTH DATE:_____/_____/____________
Are you currently or have you been credentialed or licensed as a Substance Use Disorder Professional by the MCB or any
other state or organization? ______Yes ______No
If yes, which state/organization and when? _____________________________________________________________
What is the type of credential/license held with the other state/organization?
_________________________________________________________________________________________________
Have you ever been ARRESTED and/or CONVICTED of a felony? ____Yes ____No
If yes, please go to the www.missouricb.com website, print off the “Felony Offense Form”, fill out the form and submit
with your application. If you were convicted of a felony listed in Section 630.170 RSMo (view www.missouricb.com;
Disqualifying Crimes link), you may not apply for this credential without an exception from the Department of Mental
Health.
Have you ever knowingly been contacted by a Children’s Division employee regarding a CHILD ABUSE and/or CHILD
NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.missouricb.com website, print off the “Child Abuse/Neglect Statement”, fill out the form
and submit with your application. In addition, please contact the Children’s Division at 573-751-4920 and request a
report of the incident to include with this application.
Revised August 2019 CRADC (ADC) Application
10
Education/Degree Information
Please mark your highest level of education completed:
1. High School Diploma/HSE: _____
2. Addiction Certificate Program: _____
3. Associate Degree: _____ Degree Program: ________________________
4. Bachelor Degree: _____ Degree Program: ________________________
5. Master Degree/Higher: _____ Degree Program: ________________________
An applicant may document High School Diploma or HSE or College/University degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the
applicable degree being conferred.
Where Does the Applicant Currently Work?
Name of Employer:
Mailing Address of Employer Street City State Zip Code County
Name & Title of Immediate Supervisor:
Your Business Phone: Area Code/Telephone Number Extension Fax # Area Code/Telephone Number
TRAININGS/EDUCATIONAL HOURS
The number of educational hours needed for the CRADC is as follows:
1. 300 Hours Total
6 contact hours of live ethics training (not online or home study)
20 of the 300 hours obtained within the prior 12 months of applying
All training hours must be documented by transcripts, certificates, in-service logs or other means of qualifying
documentation.
Revised August 2019 CRADC (ADC) Application
11
Applicant’s Agreement to the Code of Ethical Practice and Professional Conduct
I have read the Current Treatment Code of Ethical Practice and Professional Conduct as listed
on the MCB web site www.missouricb.com
, MCB Ethics Code Link and agree to abide by this
code:
Print Name Date
Signature Date
AUTHORIZATION AND RELEASE
I hereby certify all of the information given herein is true and complete to the best of my knowledge and
belief. I also authorize any relevant investigations, or the release of personal information to the Missouri
Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. I understand
falsification of any portion of this application/renewal will result in my being denied credentialing, or
revocation of same upon discovery.
I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff, peer
evaluators and examiners, free from any civil liability for damages or complaints by reason of any action that is
within the scope and arise out of the performance of their duties which they, or any of them, may take in
connection with this application/renewal, any examination, the grades with respect to any examination, and/or
the failure of the MCB to issue me said credential or renewal.
This Authorization and Release shall also apply to personal information requested by the Board at any time
following credentialing in connection with any investigation concerning allegations that could lead to
disciplinary action against me.
Print Name Date
Signature Date
Revised August 2019 CRADC (ADC) Application
12
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
FAMILY CARE SAFETY REGISTRY
WORKER REGISTRATION
PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)
CHILD CARE WORKER ($9.00) PERSONAL CARE WORKER ($9.00)
xx
VOLUNTARY
REGISTRANT
ELDER CARE WORKER ($9.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00) FOSTER PARENT
(NO FEE)
SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NAME
MIDDLE NAME
MAIDEN AND PRIOR NAMES USED
SOCIAL SECURITY NUMBER
(ATTACH COPY OF SOCIAL
SECURITY CARD)
- -
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
TELEPHONE NO.
(OPTIONAL)
( )
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
CITY
STATE
ZIP CODE
COUNTY
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME
CONTACT PERSON
PHONE NUMBER
( )
ADDRESS
CITY
STATE
ZIP CODE
SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I
grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to process this
request. Futhermore, I authorized the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care Safety Registry
(FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in 210.921, subsection 1 subdivision (1) and
(2), RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective employer/employee relationships, and
screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal care setting. I
understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer of information to the FCSR within thirty (30)
days of receiving the results of the background screening determination.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my signature
below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds from your
account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further collection action may
be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)
DATE
/ /
IMPORTANT
• Individuals are required to register one time only.
• Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
• Read back of form for instructions and information on registrant notification and appeal rights
• Send completed registration form, copy of Social Security card and required fee to:
Missouri Department of Health and Senior Services
Attn: Fee Receipts
P.O. Box 570
Jefferson City, MO 65102 MO 580-2421 (FP)
Submit this form with your application and a copy of your SS
card. If your agency has ran a FCSR check within the last 30 days,
you can submit the results with this form which may speed up the
application process. By doing so, you give permission for your
agency to share their FCSR results.
Revised August 2019 CRADC (ADC) Application
13
COUNSELOR EMPLOYMENT VERIFICATION FORM
An applicant is applying to the MCB for a Certified Reciprocal Alcohol Drug Counselor (CRADC) credential.
Please complete this form and provide a copy to the applicant to include with their application.
Applicant's Name: ___________________________________________________________________________
Supervisor's Name (Print):______________________________________________________________________
Agency: ___________________________________________________________________________________
Address: ___________________________________________________________________________________
___________________________________________________________________________________________
Telephone: _________________________________________________________________________________
E-mail: ____________________________________________________________________________________
Today’s Date: _______________________________________________________________________________
Within the last 10 years from the date listed above, please list the composite total number of hours the
applicant spent working with substance use disorder clients in the following domains: (Please list all hours
worked as this form replaces any previous employment forms submitted with prior applications)
The formula for computing hours is to take the total number of months worked within the last 10 years and
multiply that by 167 hours per month to get the total number of hours. Then divide that total number as
appropriate into the 4 domains below.
Screening, Assessment & Engagement: __________
Counseling: __________
Treatment Planning, Collaboration & Referral: __________
Professional & Ethical Responsibilities: __________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
Revised August 2019 CRADC (ADC) Application
14
SUPERVISED PRACTICUM OF THE PERFORMANCE DOMAINS FORM
INSTRUCTIONS: On this form document the number of supervised hours performed in each domain. The applicant must
have completed a total of 300 hours. The applicant must perform a minimum of 10 hours in each domain. The remaining
number of hours needed for credentialing can be in any of the domains.
Supervised hours must be provided by a MCB qualified supervisor only.
(MCB qualified supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC,
RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has completed the MCB Clinical Supervision Training.
This cannot be an immediate family member)
Applicant's Name(Print):___________________________________________________________
MCB Qualified Supervisor (Print):_____________________________________________________________________________
Agency:__________________________________________________________
Clinical Supervision Number:__________________
Total # Supervised Work Hours (Must be a minimum of 300 hours):__________________________________________________
Please indicate on the domain lines below how many of the Total # Supervised Work Hours listed above were in each domain. The
total listed on the line above should equal the sum total of the 4 domains (Must be a minimum of 10 hours listed for each domain):
Screening, Assessment & Engagement: __________ Hours
Counseling: __________ Hours
Treatment Planning, Collaboration & Referral: __________ Hours
Professional & Ethical Responsibility: __________ Hours
MCB Qualified Supervisor’s Signature:____________________________________________
Today’s Date: _____________
Revised August 2019 CRADC (ADC) Application
15
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101; 573-616-2300
COMPETENCY RATING FORM
1=Understands; 2=Developing; 3=Competent; 4=Skilled; 5=Master
INSTRUCTIONS FOR SUPERVISOR: On this form, a MCB qualified supervisor should rate the competency of the
applicant in the 10 listed areas using the rating scale 1-5 given above. For help in determining a rating for a particular area use
the competency rating forms found in your clinical supervision manual and/or the TAP 21.
(MCB qualified supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC,
RADC-P, LPC, LCSW, LMFT or Licensed Psychologist and who has completed the MCB Clinical Supervision Training.
This cannot be an immediate family member)
Practice Dimension Rating
Clinical Evaluation – Screening _____
Clinical Evaluation – Assessment _____
Treatment Planning _____
Referral _____
Individual Counseling _____
Group Counseling _____
Family Counseling _____
Client, Family, and Community Education _____
Documentation _____
Professional/Ethical Responsibilities _____
Total Rating Score _____
(Please add the scores together for each of the above practice dimensions to get a total rating score)
Applicant's Name: __________________________________________________________________
Name of Supervisor (Print): _____________________________________________________________________________________
Title: _______________________________________________________________________________________________________
Agency:_________________________________________________
Clinical Supervision Certificate#:___________________________________
Address:____________________________________________________________________________________________________
Supervisor's Signature:___________________________________________
Today’s Date: __________________________________
Revised August 2019 CRADC (ADC) Application
16
DOCUMENTATION OF DISABILITY-RELATED NEEDS
Please have this section completed by an appropriate professional (physician, psychologist, psychiatrist) to ensure that
your board is able to provide the required exam accommodations. Submitted documentation must follow ADA guidelines
in that psychological or psychiatric evaluations must have been conducted within the last three years. All
medical/physical conditions require documentation of the treating physician’s examination conducted within the previous
three months.
Professional Documentation:
I have known ___________________________________________ since _____/_____/_____ in my
Exam Candidate Date
capacity as a ______________________________________________.
Professional Title
The candidate discussed with me the nature of the exam to be administered. It is my professional opinion that,
because of this candidate’s disability described below, he/she should be accommodated by providing the special
arrangements listed below:
Description of Disability:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signed: ______________________________________________________ Title: ___________________________
Printed Name: _________________________________________________________________________________
Address: ______________________________________________________________________________________
City/State/Zip: _________________________________________________________________________________
Telephone Number: _____________________________ Email: __________________________________________
License Number: _______________________________ Date: ___________________________________________
(if applicable)
Revised August 2019 CRADC (ADC) Application
17
REQUEST FOR SPECIAL ACCOMMODATIONS
If you have a disability that requires special testing accommodations, please complete this form and the Documentation of
Disability-Related Needs and return it to your IC&RC member board for processing. The information you provide and
any documentation regarding your disability and your need for accommodations in testing will be treated with strict
confidentiality. Submitted documentation must follow ADA guidelines in that psychological or psychiatric evaluations
must have been conducted within the last three years. All medical/physical conditions require documentation of the
treating physician’s examination conducted within the previous three months.
Preferred Exam Date: ________________ Preferred Exam Location: __________________________________________
Name: ____________________________________________________________________________________________
Home Address: _____________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________
Daytime Telephone Number: __________________________________________________________________________
Email: ____________________________________________________________________________________________
Special Accommodations:
I request special accommodations for the following IC&RC ADC examination
Please provide (check all that apply):
________ Special seating or other physical accommodations
________ Reader
________ Large print exam
________ Extended testing time (time and a half)
________ Distraction-free room
________ Other special accommodations (please specify)
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Print Name: _______________________________________________________________________________________
Signature: _________________________________________________________________________________________
Date: _____________________________________________________________________________________________
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