ACT Program Application

ACT (Addiction Certificate Training)

ACT (Addiction Certificate Training) is a comprehensive program that fulfills the educational requirements mandated by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services (BSAS). This program includes the required 270 curriculum hours necessary for individuals to qualify for the International Certification Reciprocity Consortium (ICRC) exam, leading to the attainment of Licensure Alcohol and Drug Counselor (LADC) status. The ACT Program classes are currently conducted virtually. Eligibility Requirements: The ACT program is provided at no cost to High Point & Affiliated Organizations staff who have completed their 90-day introductory period of employment and work a minimum of 30 hours per week. For all other employment categories and team members within their first 90-days of employment, the ACT program is available at a discounted rate. External applicants will receive an invoice with payments due before the start of each course. Please note that course materials are not included, although many are supplied by our instructors. HPAO team members must not currently be under any disciplinary action to participate in the ACT Program. When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

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Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Gmail account is needed to access the online learning platform.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

MM slash DD slash YYYY

Current Employer(Required)

Current Position(Required)

On average, how many hours do you work per week?(Required)

Do you have prior experience in the behavioral health field? If yes, kindly specify the time frame of which you gained this experience.(Required)

What is the highest level of education you have completed?(Required)

High School Diploma or GED equivalent

Some College or Vocational Training (No Degree)

Associate's Degree (e.g., AA, AS)

Bachelor's Degree (e.g., BA, BS)

Master's Degree (e.g., MA, MS, MBA)

Doctorate or Professional Degree (e.g., PhD, MD, JD)

Licensure or Other

Please specify licensure or other education.

Please specify the purpose behind completing this application:(Required)

Instructor Application (Master level)

Student Application - LADC I (Master level)

Student Application - LADC II (Bachelor level)

Student Application - LADC II (High School or GED equivalent, some college, or Associate degree level)

Acknowledgment of Schedule(Required)

Classes for the ACT Program are held every Monday and Wednesday from 5:00 PM to 7:30 PM for approximately nine weeks, depending on holiday schedules. The program consists of six courses that must be completed to fulfill the education requirement. Do you understand and acknowledge this schedule, and are you available to attend class on these days and times for the full duration of the program?

I agree to the privacy policy.

Consent to Online/Virtual Training:(Required)

I understand that these courses are conducted virtually which will require that I have a tablet or computer with access to Google Classroom and Google Meet and that this tablet or computer is equip with a camera. All participants are required to use video feed during class to ensure participation and attendance. Exceptions from this requirement must be approved by an ACT Coordinator prior to class session.

I agree to the Consent to Online/Virtual Training:

Additional Documents

Application Requirements

Please be advised that in addition to completing this form, you will need to provide the following documentation:

All Applicants:

Updated Resume
High school diploma or equivalent (GED)
College transcripts (if applicable)
Narrative statement (Why you would be a good candidate to join the ACT program? one-page, double-spaced, 12-point font)
Student guidelines, signed by applicant

Internal Applicants:

Supervisor recommendation form

External Applicants:

Two letters of Recommendation

File

Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png, Max. file size: 2 GB, Max. files: 10.

Voluntary Demographic Information

We ask all applicants to provide the information listed below. Submission of this information is voluntary. Refusal to provide the information below will not subject you to any adverse treatment. The information you provide will be kept confidential and may only be used in accordance with applicable federal, state, and local laws and regulations.

Gender

Male

Female

Transgender

Non-binary

Non-conforming

Prefer not to say

Other

Age

18-24

25-34

35-44

45-54

55-64

65 and older

Prefer not to say

Ethnicity

Asian/ Pacific Islander

Black or African American

Hispanic or Latino

Multiracial

Native American or Alaskan Native

White or Caucasian

Prefer not to say

Other

Sexual Orientation

Heterosexual/ Straight

Homosexual/ Gay/ Lesbian

Bisexual

Pansexual

Asexual

Prefer not to say

Other

Do you self identify as a person in recovery? For example Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)

Yes

Prefer not to say

Veteran

Yes

Prefer not to say

Disability Status

Yes, I have a disability

No, I do not have a disability

Prefer not to say

Please indicate any special accommodations you may require. If none, please type N/A.

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ACT (Addiction Certificate Training)

Additional Documents

All Applicants:

Internal Applicants:

External Applicants:

Voluntary Demographic Information

Contact

Report a Patient Safety Concern or File a complaint with High Point Treatment Center/ SEMCOA

Report a Patient Safety Concern or File a Complaint with the Joint Commission