CREDENTIAL APPLICATION FOR NATIONAL CERTIFIED PEER RECOVERY SUPPORT SPECIALIST

Transcription

1 CREDENTIAL APPLICATION FOR NATIONAL CERTIFIED PEER RECOVERY SUPPORT SPECIALIST I. Personal Data If any documentation required for the NCPRSS credential application was issued under a previous name, you must submit a copy of the legal document to verify the change. (If by divorce, copy only that portion of the document showing the name change.) Dr. Mr. Ms. Name: Address: City/State/ZIP+4: Phone (work): (cell): (fax): II. Payment/Fee Information Credential: NCPRSS Application Fee: $ Amount Enclosed: $. (check/money order payable to NCC AP) Credit card amount: $. Company card Personal card MasterCard Visa America Express Full name of card holder (please print) Credit card number Expiration Date Signature Date National Certification Commission for Addiction Professionals (NCC AP) Updated Page 1 of 7

2 III. NCPRSS Credential Eligibility and Application Requirements 1. Candidate must have a High School diploma, GED or higher. Candidate must submit evidence of their high school diploma, GED or higher (diploma/transcript). 2. Candidate must have a minimum two years of recovery from Substance Use/Co-Occurring Mental Health Disorders. Candidate must self-attest to a minimum of two years of recovery from Substance Use/Co- Occurring Mental Health Disorders on page 6 of the application. 3. Candidate must have a minimum of one year full-time of direct practice (volunteer or paid) in a peer recovery support environment. Candidate must self-attest to a minimum of one year full-time of direct practice (volunteer or paid on page six of the application. 4. Candidate must provide evidence of earning 60 contact hours of peer recovery focused education and training to include education in documentation, community/family education, case management, crisis management, Recovery-Oriented Systems of Care (ROSC), screening and intake, identification of indicators of substance use and/or co-occurring disorders for referral, service coordination, service planning, cultural awareness and/or humility, and basic pharmacology. Must include a minimum of 6 hours of ethics and 6 hours of HIV/AIDS-specific training within the last six years. At least 50% of all CEs must be face-to-face. (1 hour of education/training equals 1 CE. 1 undergraduate college credit equals 10 CEs. 1 graduate college credit equals 15 CEs.) 5. Candidate must submit a signed statement that they have read and adhere to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics. 6. Two references (at least of one of which is professional). References may accompany NCPRSS application in a sealed envelope. 7. Candidate must mail application and all supporting documents with the non-refundable application fee of $235 to: NCC AP 44 Canal Center Plaza, Suite 301 Alexandria, VA A passing score on the National Certified Peer Recovery Support Specialist examination is required. Registration information for the examination will be provided once your endorsement application is approved. National Certification Commission for Addiction Professionals (NCC AP) Updated Page 2 of 7

3 IV. Education Record Training Hours Summary: Please submit copies of all training events (conference/ seminar attendance certificates, college transcript(s) and any other continuing education credits). All CE certificates must show the title of the training, name of the presenter/education provider (complete with their signature) and date that the training occurred. You may not apply the same title training more than once every two years. We ask that you do not submit duplicated CE certificates or CE certificates for trainings attended more than six years ago. Please Note: Graduate level hours (documented by transcript - 1 college credit = 15 CEs) Undergraduate hours (documented by transcript - 1 college credit = 10 CEs) Trainings hours that occurred during the last six years to include 6 CEs of Ethics and 6 CEs of HIV/AIDS or Bloodborne Pathogens (documented by CE certificates - 1 hour of training = 1 CE) Total hours (60 CEs required) Please check boxes to confirm documented training hours in the following areas: Documentation Community/Family Education Case Management Crisis Management Recovery-Oriented Systems of Care (ROSC) Screening and Intake Identification of Indicators of Co-Occurring Disorders for Referral Service Coordination Services Planning Cultural Awareness or Humility Basic Pharmacology National Certification Commission for Addiction Professionals (NCC AP) Updated Page 3 of 7

4 V. Career History In providing your employment history, please list your current position first and work backwards until you have documented the required minimum of one year of full time direct practice in a peer recovery support environment (volunteer or paid). Attach additional pages as needed. Current Employer: Address: Job title: Position held from: (month/year) to (month/year) Supervisor s Name: Phone: Supervisor s Address: Brief job description: National Certification Commission for Addiction Professionals (NCC AP) Updated Page 4 of 7

5 Previous Employer: Address: Job title: Position held from: (month/year) to (month/year) Supervisor s Name: Phone: Supervisor s Address: Brief job description: National Certification Commission for Addiction Professionals (NCC AP) Updated Page 5 of 7

6 VI-a. Confirmation of Recovery (Self-Attestation) I verify having a minimum of two years of recovery from Substance Use/Co-Occurring Mental Health and Substance Use Disorders. Applicant s Signature Date Applicant s Name (please print) Phone VI-b. Direct Practice Confirmation (Self-Attestation) I verify having a minimum of one year of full-time direct practice in a peer recovery support environment (volunteer or paid). Applicant s Signature Date Applicant s Name (please print) Phone VII. Candidate s Affirmation I certify that I meet the eligibility requirements for the National Certified Peer Recovery Support Specialist (NCPRSS) national credential, and that the information in this application and its supporting documents is accurate, correct and complete. I also certify that I do not hold a credential/license from any state that is or has been subject to criminal or ethical complaint. The National Certification Commission for Addiction Professionals (NCC AP) is authorized to contact any institution, organization or individual listed on or included with this application for verification of my substance use disorders counseling history. I understand that the NCC AP retains ownership of the NCPRSS credential and may, from time to time, make available credential holder names and other information to potential service users. Candidate s Signature/Date: Note: State licensure/certification is not required for the NCPRSS credential. National Certification Commission for Addiction Professionals (NCC AP) Updated Page 6 of 7

7 VIII. NAADAC/NCCAP NCPRSS Code of Ethics All those holding the NCC AP NCPRSS credential are required to adhere to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics. Ethics code violations may result in disciplinary actions, including loss of your credential. The full NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics is located in full at I hereby attest that I have read, understand, and will adhere to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics. Candidate s Signature: Date: Completed Personal Data. Candidate s Checklist Included check/money order or provided credit card information (The NCC AP has a no refund policy for incomplete applications.) Enclosed copy of GED, High School or higher diploma or transcript. Completed Education Section. Completed Career History Section. Candidate s Recovery and Direct Practice Confirmations. Completed Candidate Affirmation. Education/Training Certificate Copies (to include 6 hours of Ethics & 6 hours of HIV/AIDS or Bloodborne Pathogens training within the last six years). Signed statement that candidate has read, understands, and will adhere to the NAADAC/NCC AP NCPRSS Code of Ethics. Application and supporting documentation must be mailed to the address below. NCC AP 44 Canal Center Plaza, Ste 301 Alexandria, VA National Certification Commission for Addiction Professionals (NCC AP) Updated Page 7 of 7