Auricular Detoxification Specialist Info (Ads) Maryland

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MARYLAND ACUPUNCTURE BOARD
4201 PATTERSON AVENUE
BALTIMORE, MD 21215
410-764-4766
APPLICATION FOR REGISTRATION
AURICULAR DETOXIFICATION SPECIALIST (ADS)
(A non-refundable fee of $50 must be made payable (check or money order) to the Maryland State Board of Acupuncture)
AURICULAR DETOXIFICATION SPECIALIST INFORMATION
1. Name:
____________________________________________________________
2. Social Security Number: ________________________________________________
3. Date of Birth:
______________________________________________________
4. Residence Address:
________________________________________________
________________________________________________________________________
5. Business Address: ______________________________________________________
________________________________________________________________________
6. Contact Phone Number:
________________________________________________
7. ADS Email Address: ____________________________________________________
8. Maryland License/Certification Number and Expiration Date for one of the following
Health occupations:_____________________________________________________
(Please attach copy of current license)
A) An alcohol, substance abuse or chemical dependency counselor who is:
a) currently certified to practice as a certified professional counselor-alcohol and drug
counselor
b) certified to practice as a certified professional counselor-alcohol and drug
c) certified associate counselor-alcohol and drug or supervised counselor-alcohol and drug
or
d) licensed to practice clinical alcohol and drug counseling, or
B) A licensed nurse
C) A licensed psychologist who works directly with drug addicted clients of a chemical
dependency program in the counseling or treatment of those clients, or
D) A licensed certified social worker-clinical who works directly with the alcohol or drug
addicted clients of a chemical dependency program in the counseling or treatment of those
clients.

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