RRWI — CIT

CIT/CCS Supervision Program Application

This application is to be completed by CITs only.
Please complete this application in full. Your responses will help us confirm eligibility, match you with a Certified Clinical Supervisor (CCS), and report outcomes to our funding partners.
SECTION 1: Applicant Information
Do you currently reside/work in East Baton Rouge Parish?*

YesNo
Name*

Last NameFirst Name/M.I.
Email Address (Required)*

Confirmation Emailexample@example.com
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Title (Optional)
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Race/Ethnicity*

WhiteBlack or African AmericanHispanicAsianAmerican Indian and Alaska NativeNative Hawaiian and Other Pacific IslanderOther
Highest Level of Education Completed*

High School Diploma or High School EquivalencyAssociatesBachelorsMastersDoctorateProfessional Degree (e.g., JD, MD)Vocational or Technical TrainingOther
Marital Status*

SingleMarriedLegally SeparatedDivorcedWidowed
Primary Language Spoken*

EnglishSpanishFrenchGermanChineseVietnameseOther
Current Member of Armed Forces/Veteran:*

YesNo
SECTION 2: Counselor-In-Training Credentialing Information
Are you currently a CIT?*

YesNo
CIT Number*
Date CIT Credential Issued*

MonthDayYear
Date
Date CIT Credential Expires*

MonthDayYear
Date
Do you currently have a CCS?*

YesNo
If you do currently have a CCS, what is their full name and CCS number?*
Number of Documented Training/Supervision Hours Completed Toward Credential:*

0—75 hrs76—150 hrs151—225 hrs226—300 hrs
Additional Credential Information

Type N/A in the top-left box of the applicable table if you do not have any of the credentials listed below.

ADRA Credentials*

Rows	Type LAC	CAC	RAC	CIT	LPP	CPP	RPP	PSIT	CCS	CCGC	ATA
No.
Exp. Date

LASACT Certificates/Other Credentials*

Rows	Type AADC	CCJP	CCDP	CCDP-D	PRSS	LPC	LMFT	LCSW	LMSW	SAP	OTHER
No.
Exp. Date

Is there anything LASACT should know that may effect your program eligibility?
Disclaimer: LASACT does not discriminate on the basis of any responses provided on this form. All information is used solely to determine eligibility and program placement. Participation in the Recovery Ready Workforce Initiative is open to all qualified individuals regardless of race, color, national origin, sex, age, disability, religion, sexual orientation, gender identity, or any other protected characteristic.
Should be Empty:

CIT/CCS Supervision Program Application

SECTION 1: Applicant Information

SECTION 2: Counselor-In-Training Credentialing Information

Additional Credential Information