PSI Initial Certification 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

PSI Initial Certification Instructions

Applications for the PSI 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 180 training hours specifically related to prevention.
7. At least six (6) of the required 180 training hours must explicitly address prevention ethics in the PSI domains. 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: A minimum of a 2-year degree or 60 credit hours from an accredited university or college in community health, health, education or related field preferred and approved by WVCBAPP. Unofficial copies can be uploaded to this form, 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 work expereince. At least 2000 hours (1 year) of paid or volunteer work experience in which an average of 8 hours per week is devoted to planning or delivering prevention services across the 6 Domains. Volunteer work experience will not count for more than 2 years of qualifying experience.
*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.

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.
PSI Initial Certification Application

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

Read the enitre PSI 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
Date
Demographics
Name*

First Name Last 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.*

YesNo
Date of Birth *

MonthDayYear
Date
E-mail*
example@example.com
Phone Number*
Upload Photo ID*

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

PRSS-SUDPRSS-MHAADCADCPSIPSIICCJPCSCSPRSSCSPRSS-CLNONEOther
License Currently Held:*

LPCLICSWBSWLSWMD/DOMFTRNLPNNot applicableOther
First Year of Employment in the Prevention Field:*
Work Experience
At least 2000 hours (1 year) of paid or volunteer work experience in which an average of 8 hours per week is devoted to planning or delivering prevention services across the 6 Domains. Volunteer work experience will not count for more than 2 years of qualifying experience.

Unsupervised work experience and/or PRSS experience does not qualify for SUD prevention 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
Date
Is your current employment status?*

Full-time more than 36 hours+ per weekPart-time less than 36 hours per weekNA
Is your current employment prevention specific? *
Describe your current job duties:*
If not currently employed, please explain.
Current Resume *

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SUD Prevention -Specific Former Employment:

Only list former SUD prevention -specific employment
Former Employer 1
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your job duties:
Former Employer 2
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your job duties:
Former Employer 3
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
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 WVCBAPP to promote and safeguard the quality, effectiveness and competence of Prevention Specalists through the insistence of adherence to its Code of Ethics by all WVCBAPP certified PSIs.

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 located at:
www.wvcbapp.org/ethics.

The ethics committee has jurisdiction over all matters of violation and misconduct by WVCBAPP certified PSI 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 IC&RC Code of Ethics for the PSI credential 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.

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*

I agreeI disagree
Signature*

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Date*

MonthDayYear
Date
Upload Completed Affirmation of Truth (notary form)*

Available at www.wvcbapp.org Be sure to use the SUD prevention form
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Training
To meet the 300 contact hour training requirement, you must provide proper documentation for all training hours.

1. Certificates of Attendance:

• You must upload copies of certificates of attendance for all training hours.

2. College Coursework:

• If using college courses to meet training requirements, an official transcript must be sent directly from the institution to the Board office.

3. Prevention Specific Training:

• Out of the 300 required contact hours, at least 180 hours must be specific to SUD prevention.

• 6 of these 180 hours must focus on ethics in SUD prevention.

4. Online Continuing Education Units (CEUs):

• You cannot claim more than 12 online CEUs in a single 24-hour period.
- You must sort your hours into the follow categories.
Ethics Certificate Upload: Six (6) hours of SUD prevention specific ethics is REQUIRED to apply.*

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Substance Use Disorder Prevention Specific CEUs: Upload minimum of 180 hours in substance use prevention specific studies here.*

You may have more than 180 hours of SUD-specific CEUs.
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Certificate File Upload: Upload the remaining 114 contact hours of approved continuing education. *

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Upload Unofficial Higher Education Transcripts *

Send official transcripts to wvcbapp@wvcbapp.org directly from the institution.
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Highest Education Level*
Have your official higher education transcripts been sent directly to wvcbapp@wvcbapp.org from the institution?*

YesNo, but I will be requesting it to be sent.
What is the name listed on your official college transcripts?*
Used to pair the official transcripts to the application.
Provide the name of the institution from which your official transcripts are being sent.*
Supervision Experience
Supervision Requirements

180 completed hours of supervised practical experience with a minimum of 12 hours in each of the 6 performance domains. A PS II must provide supervision.

Knowledge and Skill Base

Competence in the performance knowledge areas demonstrated by obtaining a passing score on the IC&RC Prevention examination.

Required Documentation

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

1. Start and end dates of the supervised experience.

2. Total hours completed and the credentials of the supervisor (PSII).

3. Defined Learning Goals:

• Goals must demonstrate at least 12 hours of experience were completed in each of the domains.

• Goals should be specific to SUD prevention knowledge areas as outlined in the certification manual.

• 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.

4. Methods Used (Tasks & Behaviors Performed):

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

See the PS 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?*
Pay Fees via PayPal (non-refundable) You will redirected to PayPal. This section is optional. DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!
prevnext( X )
PS Application FeeCertification application fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$81.00

PS Exam FeePS exam fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$216.00

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*

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Date*

MonthDayYear
Date
Should be Empty:

PSI Initial Certification Application

Demographics

Work Experience

Current Employment:

SUD Prevention -Specific Former Employment:

Ethics

Training

Supervision Experience

Application Review and Exam Fee