Lcdc License Renewal Form - Texas Health And Human Services

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FOR OFFICE USE ONLY
TEXAS HEALTH & HUMAN SERVICES
Budget #ZZ743
LICENSED CHEMICAL DEPENDENCY COUNSELOR
Fund #191
LICENSE RENEWAL APPLICATION
Rec #____________
$_______________
NAME
ADDRESS
LICENSE #
_________________________________________________________________________________________________
EMPLOYMENT INFORMATION
________________________________________________________________________________
FACILITY/PRACTICE NAME
YOUR TITLE
__________________________________________________________________________________________
BUSINESS PHONE
HOME PHONE
□ Yes
□ No
Are you bilingual?
If yes, what language(s)?
__________________________________________
________________________________________________________________________________________________
Late Renewals: If you are submitting this renewal request after the date your license expired, you must read, and if
true, attest to the following.
I attest that since the expiration of my license, I have not offered or provided chemical dependency counseling
services, represented myself as a chemical dependency counselor or used any name, title or designation that implies
licensure as a chemical dependency counselor. Additionally, I will not engage in activities that require a license until
my license has been renewed pursuant to Texas Occupations Code, Chapter 504.
__________________
___________
Signature
Date signed
_________________________________________________________________________________________________
Please answer the following questions regarding your continuing education courses.
(a) Have you completed the continuing education requirements as stated below? Please check the applicable answer.
24 CE hours – for LCDC’s that possess a master’s or advanced degree.
40 CE hours – for all other LCDC’s
(b) Do your completed CE hours include 3 hours in clinical supervision, if you supervise interns; 3 hours in ethics;
□ Yes □ No
and 6 hours (total) in HIV, hepatitis C, and sexually transmitted diseases?
________________________________________________________________________________________________
Please answer each of the following questions. In the past 24 months:
□ Yes □ No
(a) have you been the subject of a disciplinary action by any licensing or certification board?
(b) have you been charged, indicted, placed on community supervision, deferred adjudication or
□ Yes □ No
convicted of a class B misdemeanor or greater in any jurisdiction?
□ Yes □ No
(c) have you been the subject of any investigation alleging client abuse, neglect or exploitation?
If you have answered “yes” to any of the above, please provide the details of the disciplinary action, criminal history
incident or investigation on a separate piece of paper and attach it to the application.
_________________________________________________________________________________________________
□ Renewal Fee - $131
Please enclose the following fees with this application:
If you are submitting a late renewal, please also include the appropriate fee:
□ Late Fee (90 days or less) - $37.50 (total $168.50) □ Late Fee (more than 90 days) - $75.00 (total $206.00)
Fees shall be paid in full with a personal check, cashier's check, commercial check, or money order.
_________________________________________________________________________________________________
I hereby attest that the information provided for this application is true and correct. I understand that mis-
information is a violation of licensing laws and rules and will result in penalties that may include denial of my
application for licensure.
Signature
Date
Please submit this form with your fees to Texas Health & Human Services
P. O. Box 12197, Austin, TX 78711-2197.
Phone (512) 834-6605
Rev 09/2017

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