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Notification of finding a site must be submitted by MAY 1 for a field experience starting during Fall semester; no later than DECEMBER 1 for a field experience starting during Spring semester; and no later than APRIL 1 for a field experience starting during the Summer semester. These deadlines are non-negotiable. Failure to submit this form by the deadlines indicated above may result in a student being unable to enter the course. To fill out this form you must attest that you will complete and retain copies of the following BY THE FIRST DAY OF CLASS: 1) Substance Use Disorders Certificate Program Field Experience Registration Intent Form 2) Field Agreement 3) Supervisor Qualification Form 4) CT Initial Application Sent to Board 5) Proof of Insurance and 6) Proof of Current CT Status.

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Student Information


Site Information

Complete Site Address
Complete Second Site Address