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Clinical Training Institution (Cti) Application Form - Texas Health And Human Services

TEXAS HEALTH & HUMAN SERVICES

P. O. Box 12197, Austin, Texas 78711-2197

Phone: (512) 834-6605

FAX: (512) 834-6677

CLINICAL TRAINING INSTITUTION (CTI) PERMIT APPLICATION

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Check one:

New Application

Renewal Application for permit #___________

You must attach the following information in order to obtain approval. Application approval applies to all sites

that offer chemical dependency counseling services to predominantly substance abusing populations.

Criteria for admitting a CI into your program. The criteria must include proof of registration with the Department

and a signed ethical agreement consistent with 25 Texas Administrative Code (TAC) §140.423 – Refer to 25 TAC

§140.421(b). Please include a copy of the ethical agreement form that a prospective CI would sign.

Written outline of reading assignments and training activities based on Knowledge, Skills, & Attitudes (KSA),

broken down by each KSA dimension. (Refer to TAP 21)

ORGANIZATION INFORMATION

Name of Organization (dba if applicable) _________________________________________________________

Mailing Address _____________________________________________________________________________

City ___________________________________ State _______________ ZIP Code ______________________

Telephone number (____) _______________________ Fax number (____) ______________________________

Facility License Number ___________________

Exempt status________________________________

Number of QCC’s on staff ________________

Description of services provided where interns will be placed: _________________________________________

_____________________________________________________________________________________

CTI COORDINATOR INFORMATION

I ATTEST THAT ALL OF THE INFORMATION CONTAINED IN THIS REGISTRATION

APPLICATION IS TRUE AND CORRECT AND I SHALL ABIDE BY ALL DEPARTMENT OF STATE

HEALTH SERVICES RULES

Name of CTI Coordinator (print)________________________________________________________________

License Type and Number_________________________________________ Title________________________

Signature of CTI Coordinator_______________________________________ Date________________________

Revised 09/2017

Clinical Training Institution (Cti) Application Form - Texas Health And Human Services