West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
Event Description Form

To be used to report training events to WVCBAPP after Approved Provider Status has been obtained.
Date of Training *

MonthDayYear
Date
Approved Provider Agency/Business or Individual Name:*
Title of Training Event:*
Location of the Training:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Contact Hours*
60 minutes =1 contact hour
Domains

Check all of the domains covered in the reported training
Counseling Domains:*

Screening, Assessment, and EngagementTreatment Planning, Collaboration, and ReferralCounseling and EducationProfessional and Ethical ResponsibilitiesN/A
Prevention Domains*

Planning and EvaluationPrevention Education and Service DeliveryCommunicationCommunity OrganizationPublic Policy and Environmental ChangeProfessional GrowthN/A
Peer Recovery Support Specialist Domains*

AdvocacyMentoring/EducationRecovery and Wellness SupportEthical ResponsibilityN/A
Upload Training *

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Certificates of attendance must be provded to all participats free of charge.

I hereby attest that all information provided in this application is true and valid to the best of my knowledge.
Signature of the supervising credentialed entity:*

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Date*

MonthDayYear
Should be Empty:

Domains