Initial Application Substance Use Disorder Peer Recovery Support Specialist (PRSS-SUD)

Substance Use Disorder Peer Recovery Support Specialist (PRSS-SUD)
PRSS-SUD 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) Supervision form to be completed by supervisor
  - High School Diploma or GED
  - Job Descriptions -Must be on company letterhead
  - 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.
  - If you do not see a "Thank You" page and receive an email copy after selecting "Submit," it did not submit.
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
Do you live or work in West Virginia at least 51% of the time?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
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Employer
Use N/A if currently unemployed
First Year Employed in the Field:
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.
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Licenses:
Current credentials only
WVCBAPP Credentials:
Current credentials only
I understand that after successful submission of my application, I will receive an automatic email confirmation. If I do not receive this email, my application must be again completed. I understand this occurs because the directions at the PayPal section are not followed.
PRSS-SUD 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 yearIf unemployed use date of last employment.
End Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearIf still employed, use today's date. If unemployed use date of last employment.
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.

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Previous Employment-Optional

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:

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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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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 PDF form here.

Copy and paste this link for form access https://form.jotform.com/250278861997071
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I have sent the link to my supervisor for completion. https://wvcbapp.jotform.com/250278861997071
Statement of Personal Recovery-PRSS-SUD

The PRSS-SUD requires at least 2 years (24 months) of sustained recovery.
This statement affirms that individuals serving as Substance Use Disorder 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 health recovery experience involving the use of alcohol and/or other drugs.
- I affirm that I have not used any alcohol or other drug affecting my central nervous system, or other drug causing physical or psychological dependence, to which I was addicted or upon which I was previously dependent, within the past two years.
- I further affirm that I have not used controlled substances which were obtained illegally or misused any controlled substances which were obtained with a valid prescription order from a licensed health care provider, within the past 2 years.
- I affirm ongoing supervision provided at least one hour a week by an organization’s documented and qualified supervisory staff.
- 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 Substance Use Disorder (PRSS-SUD), 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 SUD 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 Substance Use Disorder (PRSS-SUD), 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 SUD Peer Recovery Support Specialist until I can resume such responsibilities in a safe and effective manner.
My present period of continued recovery from alcohol or other psychoactive drugs is years and months.
Signature
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 on the WVCBAPP website 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-SUD 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: 16 Hours of Peer Specific Ethics and 30 hours of peer specific training across the domains.

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How will you be paying for your application fee and testing fee?
Mailing checks or money orders will delay processing times.
I am requesting grant funding for the application fee and testing fee.
Mailing checks or money orders will delay processing times.
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.
Use to pay via PayPal: PRSS-SUD Initial Application Review & Exam Fee DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!
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PRSS-SUD Initial Application Fee

$75.00

PRSS-SUD Exam Fee

$100.00 Quantity

Total

$0.00
If PayPal was used, what agency or name is on the account?:
Signature
Date

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

Substance Use Disorder Peer Recovery Support Specialist (PRSS-SUD)

PRSS-SUD Initial Application

Demographics

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

Previous Employment-Optional

Statement of Personal Recovery-PRSS-SUD

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

Certification of Truth

Education

Use to pay via PayPal: PRSS-SUD Initial Application Review & Exam Fee DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!