30 Day Extension Request Form

30 Day Extension Request Form

Fee - Free
MHACBO allows counselors a free 30 day extension for a credential during each renewal period.

Candidate Status (CADC-R, QMHA-R, QMHP-R, CGAC-R )cannot be extended through this form. If you are trying to extend your Candidate Status, please contact us at mhacbo@mhacbo.org
Full Name*

First NameLast Name
E-mail*
Certification Number
Your certification number can be found on our online registry at www.accbo.com/registry
Home Phone Number*

Area CodePhone Number
Work Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reason for requesting extension
Should be Empty: