RRWI — CCS

CCS/CIT Supervision Program Application

This application is to be completed by CCSs only.
Please complete this application in full. Your responses will help us confirm eligibility, match you with a Counselor-in-Training (CIT), 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)*
example@example.com
Confirm Email Address (Required)*
example@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 CCS?*

YesNo
CCS Number
Date CCS Credential Issued

MonthDayYear
Date
Date CCS Credential Expires

MonthDayYear
Date
Are you currently supervising any CITs?*

YesNo
If you are supervising CITs, how many? (Skip this question if not applicable.)*

One (1)Two (2)Three (3)Four (4) or moreN/A
Do you have a caseload and/or are working full-time? (Skip this question if not applicable.)

YesNo
Do any of the CITs you are supervising live in East Baton Rouge Parish? (Skip this question if not applicable.)

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

LASACT Certificates/Other Credentials*

Rows	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?
Please Submit a Blank W-9

Cancelof
Should be Empty:

CCS/CIT Supervision Program Application

SECTION 1: Applicant Information

SECTION 2: Counselor-In-Training Credentialing Information

Additional Credential Information