PRSS-SUD Recertification Application

West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org

ADC Initial Certification Instructions

Applications for ADC certification must include the following items. Be prepared to upload the documents with this form:
1. Completed, signed, and notarized “Affirmation of Truth” form (available at www.wvcbapp.org under forms).
2. Valid government-issued photo identification.
3. Current and comprehensive resume.
4. Signed and dated acknowledgment of the WVCBAPP Code of Ethics (provided within the online application).
5. Verification of supervision hours, signed by both the applicant and their supervisor(s).
6. Documentation of a minimum of 300 training hours, with at least 70 training hours specifically related to SUD counsling,recovery, or prevention.
7. At least six (6) of the required 70 training hours must explicitly address SUD ethics in the ADC domains. At least six (6) hours in ASAM 4 training is required. Remaining training hours may be
  obtained from a relevant behavioral or human services discipline. Training hours must be categorized appropriately and uploaded to the online application.
8. Payment of the non-refundable application review and examination fee.
9. Proof of education is required: unofficial copies are accepted for high school diplomas or GEDs, but official transcripts must be sent directly to wvcbapp@wvcbapp.org for any college-level coursework or degrees
10. This form will be used to document your 6 years of work expereince.
*All fees are non-refundable. Checks or money orders should be made payable to: WVCBAPP and mailed to 436 12th St. Suite C, Dunbar, WV 25064. This will delay the application reivew up to 30 days.

If you do not see a "Thank You" page and receive an email copy after selecting "Submit," it did not submit.

Online payments are accepted at https://www.wvcbapp.org/purchase using PayPal or by submitting with this form.

*Additional information about initial applications or recertification can be located in the credential's manual available online at: www.wvcbapp.org.
ADC Initial Certification Application

Use this form to apply for the ADC credential for the first time.
Before You Begin the Application

Read the enitre ADC manual.

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.
Date of Initial Application

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

First Name Middle NameLast Name
Maiden, Nickname, or Preferred Name:
Optional
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residency Requirement: Initial applicants must live or work in West Virginia at least 51% of the time to qualify. This does not apply to recertification.
I understand that if the submission of my application is successfull, I will recieve an automatic email JotForm response. If I do not, I need to resubmit the entire application again. The most common reason for this error is not following the payment instructions
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Upload Photo ID

Required for test registration
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Certification Currently Held (select all that apply)

Other
License Currently Held:

Other
Are you in private practice?
First Year of Employment in the SUD/Prevention Field:
Work Experience
Candidates must have a total of six (6) years of qualifying experience, which can be met through a combination of direct SUD-related work experience, general work experience, and education:

• SUD Counseling Specific Work Experience: At least three (3) years (6,000 hours) of direct work experience in the substance use disorder field. Additional time in this category can be applied toward the total six-year requirement.

• General Work Experience: Up to three (3) years of general work experience may count toward the six-year requirement. General work experience may include peer based services, not SUD counseling specific.

Candidates with higher education in a related field may substitute education for part of the work experience requirement:

• High School Diploma: 6,000 hours (3 years required) of SUD-specific supervised work experience.

• Associates degree: 5,000 hours (2.5 years required); may replace up to 1,000 hours of work experience.

• Bachelor’s Degree: 4,000 hours (2 years required); may replace up to 2,000 hours of SUD-specific experience.

• Master’s Degree or Higher: 2,000 hours (1 year required); may replace up to 4,000 hours of SUD-specific experience.

Unsupervised work experience and/or PRSS experience does not qualify for SUD counseling specific work.

Time in personal recovery should not be listed here.
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is your current employment status?
Is your current employment SUD counseling specific?
Describe your current job duties:
If not currently employed, please explain.
Are you using a college degree as part of the required work experience?
Current Resume

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SUD Counseling -Specific Former Employment:

Only List former SUD counseling -Specific Employment
Former Employer 1
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What was your employment status?
Describe your job duties:
Former Employer 2
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What was your employment status?
Describe your job duties:
Former Employer 3
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What was your employment status?
Describe your job duties:
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional Former Employer 4
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional Former Employer 5
Ethics
Ethical Code of Conduct

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

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 IC & RC for the CS, CCJP, PSI, PSII credentials, and NAADAC Code of Ethics for ADC, AADC located at:
www.wvcbapp.org/ethics.

The ethics committee has jurisdiction over all matters of violation and misconduct by WVCBAPP certified ADC in the state of West Virginia. It immediately and thoroughly investigates such charges and makes recommendations to the Board of Directors for appropriate action.

AFFIRMATION OF TRUTH:.

I hereby attest that I have read, understand, and will adhere to the NAADAC Code of Ethics for the ADC and AADC credentials including, a subsequent change to the code of ethics that is duly approved by the NAADAC 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.

I understand that agreeing and signing below indicates that this application is truthful. Deception on this form is a violation of the Ethical Code of Conduct and may result in sanctions, suspensions or revocations of certification.
Ethical Code of Conduct Affirmation of Truth
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Completed Affirmation of Truth (notary form)

Available at www.wvcbapp.org Be sure to use the ADC/AADC form
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Training
West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org

ADC Initial Certification Instructions

Applications for ADC certification must include the following items. Be prepared to upload the documents with this form:
1. Completed, signed, and notarized “Affirmation of Truth” form (available at www.wvcbapp.org under forms).
2. Valid government-issued photo identification.
3. Current and comprehensive resume.
4. Signed and dated acknowledgment of the WVCBAPP Code of Ethics (provided within the online application).
5. Verification of supervision hours, signed by both the applicant and their supervisor(s).
6. Documentation of a minimum of 300 training hours, with at least 70 training hours specifically related to SUD counsling,recovery, or prevention.
7. At least six (6) of the required 70 training hours must explicitly address SUD ethics in the ADC domains. At least six (6) hours in ASAM 4 training is required. Remaining training hours may be
  obtained from a relevant behavioral or human services discipline. Training hours must be categorized appropriately and uploaded to the online application.
8. Payment of the non-refundable application review and examination fee.
9. Proof of education is required: unofficial copies are accepted for high school diplomas or GEDs, but official transcripts must be sent directly to wvcbapp@wvcbapp.org for any college-level coursework or degrees
10. This form will be used to document your 6 years of work expereince.
*All fees are non-refundable. Checks or money orders should be made payable to: WVCBAPP and mailed to 436 12th St. Suite C, Dunbar, WV 25064. This will delay the application reivew up to 30 days.

If you do not see a "Thank You" page and receive an email copy after selecting "Submit," it did not submit.

Online payments are accepted at https://www.wvcbapp.org/purchase using PayPal or by submitting with this form.

*Additional information about initial applications or recertification can be located in the credential's manual available online at: www.wvcbapp.org.
Ethics Certificate Upload: Six (6) hours of SUD/prevention specific ethics is REQUIRED to apply.

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ASAM 4 Certificate Upload: Six (6) hours ASAM4 training is REQUIRED to apply.

Effective 1/1/2027
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Substance Use Disorder or Prevention Specific CEUs: Upload minimum of seventy (70) hours in substance use or prevention specific studies here.

You may have more than 70 hours of SUD-specific CEUs.
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Certificate File Upload: Upload the remaining twenty-eight (224) contact hours of approved continuing education.

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Upload Unofficial Higher Education Transcripts OR HS Diploma/GED

Optional
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Highest Education Level
Have your official higher education transcripts been sent directly to wvcbapp@wvcbapp.org from the intuition?
What was your legal name at the time of your graduation?
Used to pair the official transcripts to the application.
Provide the name of the institution from which your official transcripts are being sent.
Name of high school/GED or college
Supervision Experience
Supervision Requirements

A college practicum/internship in a human services field may be used to fulfill supervision requirements but is not mandatory.

An example of a revisable supervision form and log in sheet is under the forms section of www.wvcbapp.org.

The supervised experience consists of hands-on work during which the applicant receives required supervision hours from a qualified supervisor:

•ADC-S, AADC-S, or AADC must provide at least 50% of this supervision.

• ADC without a CS credential may supervise up to 50% the SPE for the ADC only.

• Other supervisors must be licensed or credentialed in a human services field to qualify and can only provide 50% of the supervsion.

The required amount of supervision varies based on the applicant’s level of education:

High School Diploma or Equivalent =300 Hours
Associate Degree in a Related Field=250 Hours
Bachelor Degree in a Related Field=200 Hours
Masters Degree or Higher in a Related Field=100 Hours

Required Documentation

To ensure compliance with certification standards, applicants must document the followng:

1. Start and end dates of the supervised work experience.

2. Total hours completed and the credentials of the supervisor (ADC-S, AADC-

S, or AADC).

3. Defined Learning Goals:

• Goals must demonstrate that at least 10 hours of experience were completed in each of the domains.

• Goals should be specific to substance use knowledge areas as outlined in the certification manual’s

• These goals should clearly describe what was learned during the supervision.

• Learning goals may be developed by the applicant alone or with their supervisor.

• Both the applicant and supervisor must sign the form.

• Letters of reference from a work supervisor do NOT replace the required supervision documentation.

4. Methods Used (Tasks & Behaviors Performed):

• Document the specific tasks and professional activities performed in each domain.

See the ADC manual for more details.
Upload Signed Supervision Documentation

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Application Review and Exam Fee

Non-refundable
How will you be paying the fee?
STOP! READ: IMPORTANT PAYMENT INSTRUCTIONS: Only check the box beside a fee amount below if you are paying that fee immediately through PayPal as part of this application. If you check a payment box, you will be redirected to PayPal. You must completethe payment at that time. After payment is completed, PayPal will redirect you back to the application so you can finish and submit. If you check a payment box and then exit PayPal without completing payment, your application information will be lost and you will have to start the application over. If you are not paying through PayPal right now, DO NOT CHECK ANY OF THE PAYMENT BOXES. Instead, you may submit your application and then: Mail a check or money order, or Visit wvcbapp.org to make your payment separately. Checking the box means: “I am payingthis amount through PayPal right now.”
Pay Fees via PayPal (non-refundable). This section is optional. DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!
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ADC Application Fee

$125.00

ADC Exam Fee

$225.00

Total

$0.00
If PayPal was used, what agency or name is on the account?:
Example: Jon Dower or FMRS Health Systems
I affirm that the information contained in this application is true, and that I have attended all training and education uploaded at attached to this document. I adhere to the appropriate Ethical Code of Conduct for my credential(s). Signature
Date

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

ADC Initial Certification Application

Demographics

Work Experience

Current Employment:

SUD Counseling -Specific Former Employment:

Ethics

Training

Supervision Experience

Application Review and Exam Fee

Pay Fees via PayPal (non-refundable). This section is optional. DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!