IBADCC Continuing Education Provider Application

IBADCC Continuing Education Provider Application

To apply for IBADCC endorsement of your continuing education program, please scroll down to complete the application form with the necessary attachments and the non-refundable processing fee. **Note: This form contains 5 sections.
Date of Application*

MonthDayYear
Date

Section I. Sponsor Information
Name of Agency*
Agency Website*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Section III. Program Overview

Please attach a program review including the following information:

1) Measurable learner objectives that are consistent with the Counselor Core Function Areas:

Screening	Orientation	Record Keeping
Intake	Referral	Case Management

2) Brief program and/or course description

3) Timed agenda, including registration, breaks, and meals

4) Certificate of completion that includes: The sponsoring agency’s name, number of contact hours, title and date of program, participant’s name, IBADCC endorsement and provider number, and signature.

5) Method of determining successful completion (Evaluation instruments)

6) Name of instructors and bios including the education and experience background that qualifies them to be presenters of their identified topic.

Upload Program Overview*

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Sections IV. Fees
All IBADCC members receive the following benefits included with their endorsement fee: listing on the IBADCC website as an approved provider, registration link to the program on the IBADCC website, one listing
in the educational offerings section of the IBADCC newsletter, one social media post, and 50% off additional marketing add-ons.

IBADCC non-members receive the following benefit included with their endorsement fee: listing on the IBADCC website as an approved provider. Additional marketing opportunities can be added to the total fee.

Applications must be accompanied by the appropriate reviewing fee as follows:

IBADCC Member Rate
1-5 CE hours / $30
6-10 CE hours / $65
11-15 CE hours / $95
16+ CE hours / $95 + $8 per hour

Non-IBADCC Member Rate
1-5 CE hours / $65
6-10 CE hours / $130
11-15 CE hours / $195
16+ CE hours / $195 + $15 per hour

Marketing Add-ons
Program Listing and Registration link on IBADCC’s website for 6 months/ $100
Standalone email blast to all IBADCC members promoting approved CE program / $200 per email
Weekly Newsletter Advertisement / $100 per ad
Social media post promoting approved CE program /$50 per post

Signature
Authentication: I hereby attest that the information provided in this application is valid and that the material presented in this education package is not in any violation of copyright laws and do not conflict with any ethical code established for the addictions field.
Full Name*
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: