Initial Application Mental Health Peer for Currently Certified PRSS-SUD Recovery Support Specialist (PRSS-MH)

Mental Health Peer Recovery Support Specialist (PRSS-MH)
PRSS-MH Initial Application for Current PRSS-SUD Credential Holders

Only use this form if you hold a current, valid PRSS-SUD certification.
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) to print, complete, scan, and upload to this form.
  - Current, valid, unexpired PRSS-SUD certification certificate
  - 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.
  - Make sure all documents are properly formatted and ready for submission before starting your application.
Demographics
Name

First NameMiddle NameLast Name
Nickname, Maiden, or Preferred Name:
Personal Email
example@example.com Do NOT use work email addresses
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
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Use N/A if currently unemployed
Highest Academic Degree
File Upload Current Valid Unexpired PRSS-SUD Certification

Must be an official WVCBAPP PRSS-SUD certificate. Do not upload letters or wallet cards.
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Licenses:
Current credentials only
WVCBAPP Credentials:
Current credentials only
PRSS-SUD Certification Number
Can be found on official PRSS-SUD certificate issued by WVCBAPP.
I understand that I will immediately receive an automatic email confirming sumbission of my application. I understand that if I do not, I must again complete the form. I understand this error is caused by not following the instructions at the PayPal portion of this form.

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. If unemployed use dates last employed in the field.
Primary Responsibilities:

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.

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Previous Employment-Optional

Please only include PRSS related positions. This section 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:

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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
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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-MH 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.
My present stable state of recovery from my mental health condition is years* and months.*
Do you have any ethical complaints outstanding including self-reported use?
Are you currently working as a PRSS directly with clients?
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.
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Education

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

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File Upload: 2 hours of Suicide Prevention Education

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File Upload: 7 hours of Mental Health Specific Training

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I am requesting grant funding for my application fee. This does not delay the review process.
How will you be paying for the application and testing fees?
Add an extra two weeks for processing if mailing payment.

STOP: DO NOT CHECK THE BOXES BELOW IF YOU ARE NOT PAYING VIA PAYPAL USING THIS FORM. YOU WILL BE REDIRECTED TO PAYPAY IF YOU DO, AND IF YOU DO NOT PAY AT THAT MOMENT, YOUR INFO WILL BE LOST. DO NOT CHECK THE BOXES IF YOU HAVE OR INTEND TO PAY VIA PAYPAL ON WVCBAPP.ORG OR IF YOU ARE MAILING A CHECK/MONEY ORDER.
PRSS-MH Initial Application Review Fee DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!
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PRSS-MH Initial Application Fee for Current PRSS-SUD Upgrade Fee

$50.00

Total

$0.00
I hereby certify that the statements contained in this application and supporting documents, given for consideration of my application for certification as an Peer Recovery Support Specalist for Mental Health (PRSS-MH) are, to the best of my knowledge, true and correct. I acknowledge that fees are non-refundable.

I further certify that I have read and subscribe to and abide by the WVCBAPP Code of Ethics. I authorize the Board to conduct inquiries or interviews as they deem necessary.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Mental Health Peer Recovery Support Specialist (PRSS-MH)

PRSS-MH Initial Application for Current PRSS-SUD Credential Holders

Demographics

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

Previous Employment-Optional

Statement of Personal Recovery-PRSS-MH

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

Certification of Truth

Education

PRSS-MH Initial Application Review Fee DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!