Request edit access
Student Registration Form
Please complete this form prior to first enrolling  with About Addiction Counseling. 
Sign in to Google to save your progress. Learn more
Email *
Full Name *
First and last name
Date of Birth *
MM
/
DD
/
YYYY
Email *
Phone number *
Address *
Preferred Method of Contact *
Required
Do you consent to receiving information about promotions offered via email? *
Do you have experience working in the Substance Use Field? *
Are you currently working in the Substance Use Field? *
If you are working in Substance Use; describe your job title and length of time employed? *
I'm currently registered with *
SUDRC Registration Number
Initial SUDRC Registration Date
MM
/
DD
/
YYYY
Why do you want to become a Certified SUD Counselor? *
How soon are you ready to start your courses? *
How many hours a week do you have to dedicate to your course work? *
Which Course(s) are you interested in? *
Required
How did you hear about us? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms