CACCB - Canadian Addiction Counsellors Certification Board
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Please Print and Fax this form to 519 772-0535

Thank you for your interest in applying for your membership to the Canadian Addiction Counsellors Certification Federation.

Please fill in the information below to complete your membership application. Fields with the red asterisk * are required. After you have completed the application Please Print and Fax this form to 519 772-0535.

* Required fields

Personal Information
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Name*
Email Address*
Organization
Business Address
Street*
City*
Province*
 If other
Postal Code*
Country*
Telephone*
Fax Number
Residence Address
Same as above
Street
City
Province
If other
Postal Code
Country
Telephone
Fax Number
Please send mailings to:*
Business Address Residence Address
Tell Us About Yourself
How did you hear about C.A.C.C.F.?
College/University Employer Internet Other
Which of the following best describes your place of work?
Treatment (Hospital Based) Treatment (Community Based)
Assessment/Referral Recovery Home
Withdrawal Management Private Practice
Other
Which of the following best describes your primary job function?
Counsellor Clinical Supervisor
Administrator Therapist
Consultant Other
What are your areas of interest?
Youth Relapse Prevention
Fetal Alcohol Syndrome Harm Reduction
Mental Health Problem Gambling
Suicide Prevention EAP's
Women and Addictions Substance Abuse and the Elderly
Prevention Male Adult and Addictions
Aboriginal Abstinence
Corrections Other
Would you like to be added to our membership directory. Yes No
Credit Card Billing Information

Please Note: All Personal and credit information submitted must be valid.
For security purposes, any information submitted will be subject to verification.

Cardholder's Name*

Billing Address

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Postal Code*
Country*
Telephone*

Credit Card Information

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Card Number*
Expiration Date*
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Type of Membership

  Canadian Addiction Counsellors Initial Membership
  Special Stud  ent Membership Fee*

*Must provide proof of full time student status in an Addiction or Human Services program

Issuing Bank:
* Canon of Ethics

Click here to read the Canon of Ethics. The document is in PDF Format.

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You may print a copy to keep in your records. After you have read it and agreed with the principles included, check the button below to continue:

* Yes, I have read and subscribe to the Canon of Ethics of the Canadian Addiction Counsellors Certification Board
* I could not open/read the Canon of Ethics PDF File. Please send me a copy by regular mail.
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Please Print and Fax this form to 519 772-0535
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Downloads

     Canon of Ethics 
         [PDF ~ 41K]

     Membership 
         Brochure 
         [PDF ~ 453K]

       Membership 
         Application Form
         [PDF ~ 21K]