Counselor Certification Renewal Application
Please fill out all required fields to renew your certification.
Full Name
*
First Name
Last Name
License Number
*
Renewal Year
*
Educational Background and Credentials
*
Specializations
*
Please Select
Addiction Counseling
Mental Health Counseling
Family Therapy
Other
Relevant Continuing Education Completed
*
Employer or Practice Name
*
Contact Email
*
Phone Number
*
Terms & Conditions
*
1
I agree to the terms and conditions regarding certification renewal.
Submit
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