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Licensed Chemical Dependency Counselor Application ...

Page 1 of 3 Revised 6/2020 Licensed Chemical Dependency Counselor Application Licensure by Exam/Internship ( Counselor Intern Registration) Mail your completed Application packet with $65 to: HHSC ARTS LCDC MC 1470, PO Box 149055 Austin, TX 78714-9055 (512) 834-6605 FAX (512) 834-6677 Initial Registration Subsequent Registration (refer to 25 Texas Administrative Code ) Section I Personal Information Social Security Number Last Name First Name Middle Initial Mailing Address City State ZIP Code County ( ) Female Male Home Phone Gender ( ) Work Phone Date of Birth Are You Bilingual?

Licensed Chemical Dependency Counselor Application– Licensure by Exam/Internship(Counselor Intern Registration) Mail your completed application packet with $65 to: HHSC ARTS LCDC. MC 1470, PO Box 149055 Austin, TX 78714-9055 (512) 834-6605 FAX (512) 834-6677 Initial Registration Subsequent Registration

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