Initial Application Mental Health Peer Recovery Support Specialist (PRSS-MH)

Mental Health Peer Recovery Support Specialist (PRSS-MH)

Do NOT use this form if you are currently credentialed as a PRSS-SUD with WVCBAPP.
PRSS-MH Initial Application
Before You Begin the Application
1. Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.
2. During the online application process, you will need to upload the following official WVCBAPP forms and supporting documents:
  - Certification of Truth-Notarized (Available at www.wvcbapp.org)
  - Supervision Form -Completed by your supervisor (Available at www.wvcbapp.org)
  - High School Diploma or GED
  - Job Descriptions -Must be on company letterhead
  - Current Mental Health First Aid Certificate OR Taking Action Course
  - All Education Certificates -A complete list of required certificates can be found in the PRSS Manuals on the WVCBAPP website.
  - Valid Photo Government Issued ID
  - Make sure all documents are properly formatted and ready for submission before starting your application.
Are you a current PRSS-SUD with WVCBAPP in good standing?
Demographics
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameMiddle NameLast Name
Nickname, Maiden, or Preferred Name:
Personal Email
example@example.com Do NOT use work email addresses
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
File Upload: Valid Photo Government ID

Your valid government-issued photo ID must match the name and address provided on this form. Failure to meet this requirement will result in denial of admission to the testing center.
Cancelof
Employer
Use N/A if currently unemployed
Gender
This is used for test registration and must match your ID
Highest Academic Degree
File Upload High School Diploma or GED

College courses require official transcripts sent to wvcbapp@wvcbapp.org directly from the issuing college or university.
Cancelof
Licenses:
Current credentials only
WVCBAPP Credentials:
Current credentials only
I understand that after a successful sumbission of this application that I will receive an automatic email confirming. I understnad that if I do not, the entire applcation must be again completed. I understand this error occurs by not following directions in the PayPay section.

PRSS-MH RELATED EMPLOYMENT, PAID OR VOLUNTEER, 500 HOURS REQUIRED. DO NOT INCLUDE TIME IN TREATMENT.

Primary Responsibilities must be in your own words and CAN NOT be left blank.
Current Employer:
If unemployed, type N/A
Current Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Title:
If unemployed, type N/A
Immediate Supervisor:
If unemployed, type N/A
Hours Per Week
If unemployed, type 0
Hire Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearIf still employed, use today's date.
Primary Responsibilities: (If unemployed, how did you obtain the 500 hours)

This cannot be left blank and must be in your own words. 0/0
Upload a job description (on company letterhead) from CURRENT/PREVIOUS employer verifying your duties and dates employed.

Cancelof

Previous Employment

Please only include PRSS related positions. This sections is optional if you have met the 500 hours at your current employer.
Previous Employer 1: Optional
Previous Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Title:
If unemployed, type N/A
Immediate Supervisor:
If unemployed, type N/A
Hours Per Week
If unemployed, type 0
Hire Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Responsibilities:

This cannot be left blank and must be in your own words. 0/0
Job Description from Former Employer 1:

Cancelof
Previous Employer 2: Optional
Previous Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Title:
If unemployed, type N/A
Immediate Supervisor:
If unemployed, type N/A
Hours Per Week
If unemployed, type 0
Hire Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Responsibilities:

This cannot be left blank and must be in your own words. 0/0
Job Description from Former Employer 2

Optional
Cancelof

How will you be submitting your proof of supervision?
Supervisor Completing the Supervision Form

First NameLast Name
Supervisor's Credentials:
LPC, AADC, LICSW, PRSS-MH/SUD etc.
Phone Number of the Supervisor Completing the Supervision Form
Please enter a valid phone number.Format: (000) 000-0000.
Email of the Supervisor Completing the Supervision Form
example@example.com
File Upload: SUPERVISION-To be completed by the supervisor. Form can be found at https://form.jotform.com/250278861997071 please email the link to your supervisor or upload the physical form here

Copy and paste this link for form access https://form.jotform.com/250278861997071
Cancelof

Statement of Personal Recovery-PRSS-MH

Requires 2 years (24 months) of a stable state of recovery from a MH condition.
This statement affirms that individuals serving as Mental Health Peer Recovery Support Specialists have successfully navigated their own recovery journeys and are currently in a stable state of recovery. They have achieved the ability to manage their personal challenges in a way that does not interfere with their professional responsibilities or the quality of support they provide to others.
- I, the undersigned individual, affirm that I have successfully pursued my own personal mental health recovery experience involving a mental health disorder and are in a stable state of recovery.
- I affirm ongoing supervision provided at least one hour a week by an organization’s documented and qualified supervisory staff while I am providing services in the PRSS capacity.
- I further affirm that, in the event I experience a recurrence of mental health symptoms that may interfere with or impair my functioning as a Peer Recovery Support Specialist in Mental Health (PRSS-MH), I will take the following steps:
  - Seek appropriate therapeutic care to address the symptoms.
  - Notify WVCBAPP in writing of my condition and its potential impact on my professional duties.
  - Refrain from providing services as a Mental Health Peer Recovery Support Specialist until I can resume such responsibilities in a safe and effective manner.
Select all that apply:

Agree: I further affirm that, in the event I experience a recurrence of mental health symptoms that may interfere with or impair my functioning as a Peer Recovery Support Specialist in Mental Health (PRSS-MH), I will take the following steps: Seek appropriate therapeutic care to address the symptoms. Notify WVCBAPP in writing of my condition and its potential impact on my professional duties. Refrain from providing services as a Mental Health Peer Recovery Support Specialist until I can resume such responsibilities in a safe and effective manner.
Do you have any ethical violations under investigation or outstanding including self-reported use?
My present stable state of recovery from my mental health condition is years and months.*
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Peer Recovery Support Specialist-SUD/MH Ethical Code of Conduct
Peer Recovery Support Specialist-SUD/MH Ethical Code of Conduct

It is the policy of the West Virginia Certification Board for Addiction and Prevention Professionals to promote and safeguard the quality, effectiveness, and competence of Peer Recovery Support Specialists through the insistence of adherence to its Code of Ethics by all WVCBAPP certified Peer Recovery Support Specialists.

The ethics committee develops and recommends an ethical code of conduct for adoption by the Board of Directors. Currently, the Board has adopted the code of conduct adhered to by the IC & RC Code of Ethics which are available on the WVCBAPP website. Code of Ethics-ICRC-PRSS-revised. The ethics committee has jurisdiction over all matters of violation and misconduct by WVCBAPP certified Peer Recovery Support Specialists in the state of West Virginia. It immediately and thoroughly investigates such charges and makes recommendations to the Board of Directors for appropriate action.

I hereby attest that I have read, understand, and will adhere to the IC&RC Peer Recovery Code of Ethics, available at www.wvcbapp.org/ethics and including, a subsequent change to the code of ethics that is duly approved by the IC&RC Board of Directors at a regularly scheduled Board Meeting. It is my responsibility to remain current and comply with the code of ethics for this and other credentials awarded by my credentialing body throughout the life of the credential.
- Signature below denotes that applicant:
  - is free of any ethical or malpractice violation; and accepts all the principles of the IC& RC Code of Ethics and disciplinary procedure.
  - has personally completed this application and understands no person or entity, including but not limited to the employer, may complete the application on my behalf.
  - understands the PRSS-MH is not a substitute or a replacement for a Right to Practice credential and is therefore not a license with which to practice substance use disorder or mental health counseling.
Select all that apply:
Applicant Signature
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Certification of Truth
File Upload: Notarized Certification of Truth. Official form can be found at www.wvcbapp.org

Only the official form will be accepted.
Cancelof
Education

Please upload certificates in the correct upload location.
File Upload: 6 hours+ Unexpired Mental Health First Aid Certificate OR Taking Action Course

Cancelof
File Upload: 16 Hours of Peer Specific Ethics and 30 hours of peer specific training across the domains.

Cancelof
File Upload: 2 hours of Suicide Prevention Education

Cancelof
File Upload: 7 hours of Mental Health Specific Training

Cancelof
How will you be paying the application fee and testing fee?
Please note that mailing money order or checks extends the processing time.
STOP AND READ: DO NOT CHECK THE BOXES BELOW NEXT TO THE PAYMENT AMOUNTS IF YOU ARE NOT USING PAYPAL ON THIS FORM. DO NOT CHECK THE BOXES IF YOU HAVE OR INTEND TO PAY VIA PAYPAL ON THE WEBSITE. DO NOT CHECK THESE BOXES IF YOU ARE MAILING PAYMENT. ONCE YOU ARE REDIRECTED TO PAYPAL, IF YOU DO NOT PAY, YOUR INFORMATION WILL BE LOST AND NOT SUBMITTED.
I am requesting grant funding for my application and testing fees.
Please note that mailing money order or checks extends the processing time. Grant funding does not delay the review process.
Check only if using PayPal PRSS-MH Initial Application Review Fee
prevnext( X )
PRSS-MH Initial Application Fee

$75.00

PRSS-MH Testing Fee

$100.00

Total

$0.00
If PayPal was used, what agency or name is on the account?:
Example: Jon Dower or FMRS Health Systems
Should be Empty:

Mental Health Peer Recovery Support Specialist (PRSS-MH)

PRSS-MH Initial Application

Demographics

PRSS-MH RELATED EMPLOYMENT, PAID OR VOLUNTEER, 500 HOURS REQUIRED. DO NOT INCLUDE TIME IN TREATMENT.

Previous Employment

Statement of Personal Recovery-PRSS-MH

Peer Recovery Support Specialist-SUD/MH Ethical Code of Conduct

Certification of Truth

Education

Check only if using PayPal PRSS-MH Initial Application Review Fee