National Certified Peer Specialist (NCPS) Application

National Certified Peer Specialist (NCPS)
At the time of application, successful candidates:
- hold an active, recognized peer specialist/peer support credential from their state or governing jurisdiction OR have completed 40 hours of competency-specific training,
- have 2,000 hours of work or volunteer experience providing peer support/peer specialist services within the 5 years prior to application,
- can provide three letters of recommendation for certification, and
- pass the NCPS multiple choice exam of core competency.
This application captures early information used to create a full application. You will submit peer certification or training documentation. Your current or former employers will submit documentation verifying your related work experience, and three other individuals will submit letters of recommendation in support of your application for NCPS.

After these requirements are approved by the Board, you may register for the NCPS exam. The NCPS credential is awarded after passing the exam.

Please see the NCPS requirements document for specific requirements and details.

Your Information
1. Title*
2. First Name*
As shown on your government issued Identification.
2a. Preferred Name
If you go by a name other than what is on your government issued Identification.
3. Middle Name*
As shown on your government issued Identification.
4. Last Name*
As shown on your government issued Identification.
5. Suffix*
6. Last 4 of SSN*
7. Email Address (personal)*
example@example.com
8. Date of Birth*

MonthDayYear
Date
9. Gender*
10. Race*
11. Ethnicity*

Mailing Address & Employment Information
12. Mailing Address (personal)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
13. Phone Number (personal)*

Area CodePhone Number
14. Current Employer Name*
15. Current Employer Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
16. Employer Phone Number*

Area CodePhone Number
17. Employer Website

Criminal Background
18. Have you ever been convicted, plead no contest, or had an adjudication of guilt withheld for any crime which is a felony or 1st degree misdemeanor?*

Yes (If yes, the Board will contact you for additional information.)No
19. I understand that the Board will not conduct a criminal history check as part of the application process and my certification does not waive any employment related criminal history requirements.*

Yes
20. I understand that if I am found guilty of a first-degree misdemeanor, any felony, or otherwise deemed ineligible to work with the behavioral health population, my credential will be placed in summary suspension status pending the outcome of any necessary investigation by the Board into my conduct.*

Yes
21. I understand that the Board's Code of Ethical and Professional Conduct is posted on the Board's website and it is my responsibility to download, read, understand, and comply with the Code as well as the published Disciplinary Procedures.*

Yes

Formal Education

The NCPS requires a high school diploma, general equivalency degree, or higher. Please enter the information about your highest level of education completed.
22. Name of School*
23. City/State*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
24. Formal Education Level*
25. Program of Study/Major*
26. Month and Year of Graduation*

MonthDayYear
Date
27. You are required to provide a minimum of a high school diploma and/or transcripts.

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Supervised Work Experience
Applicants must have 2,000 hours of experience providing peer specialist services. Eligible experience occurred in the 5 years before application.

In this section, identify each employer who will be responsible for documenting the NCPS supervised work experience requirement. Then, download and provide a copy of the Board’s NCPS Verification of Supervised Work Experience Form to each identified employer.

Employers will complete the form and submit it directly to the Board for review. The Board will not accept documentation submitted by the applicant.
28. Add information about your eligible current or former supervisors
28a. Supervisor Name*
28b. Supervisor Phone Number*

Area CodePhone Number
28c. Supervisor Email Address*
example@example.com
28d. Supervisor Employer*
28e. Supervisor Position Title*
28f. Add another eligible current or former supervisor*

YesNo

29. Add an additional eligible current or former supervisor
29a. Supervisor name #2
29b. Supervisor phone number #2

Area CodePhone Number
29c. Supervisor Email Address #2
example@example.com
29d. Supervisor Employer #2
29e. Supervisor Position Title #2

Content Specific Training
Applicants must complete 40 hours of peer specialist training within the 5 years before application.

The NCPS training requirement can be met in one of the following ways. Select the way you will submit training documentation.
- I hold a peer specialist/peer support credential from my state or jurisdiction.
- I completed a Board approved 40-hour peer specialist training program within the 5 years prior to application.
- I completed multiple training events that, in total, met the 40 hours training requirement.
Applicants are responsible for providing training documentation to the Board in a clear and organized manner.
1. Download the NCPS Training Verification Form from the Board’s website.
2. Complete the form by entering the requested information.
3. Collect certification or training documentation, assemble documents in the same order as listed on the NCPS Training Verification Form, create an electronic file of training documentation.
4. Upload the completed NCPS Training Verification Form and the training documentation e-file to the NCPS application.
30a. Select the “Choose File” button to upload your electronic NCPS Training Verification Form file.*

File formats: pdf, doc, docx, txt, wpd, xls, xlsx, jpg, png (max size 20mb)
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30b. Supporting documentation

File formats: pdf, doc, docx, txt, wpd, xls, xlsx, jpg, png (max size 20mb)
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Professional Recommendations

Applicants must have three (3) letters of recommendation for certification as a NCPS.
Access the here: NCPS Recommendation Form

If you would like to share this form you can copy this link:

https://form.jotform.com/241155953346156

Attestations
31. I give my permission to the Board and its staff to investigate my personal and professional background as it relates to this application for professional certification, to include all provided information, statements of understanding, agreements, and associated supporting documents used to determine and verify my eligibility for certification.*

Yes
32. I consent to the release of the information contained in my application, to include all supporting documentation and any other pertinent source of information collected by or submitted to the Board in relation to my application to its officers, staff, members of the Board of Directors, and members of Board advisory councils and review committees.*

Yes
33. I consent to the release of the information contained in my application, to include all supporting documentation and any other pertinent source of information collected by or submitted to the Board in relation to my application to its officers, staff, members of the Board of Directors, and members of Board advisory councils and review committees.*

Yes
34. I understand that this application, including all supporting documentation, must be approved by the Board in its entirety before I will be approved to register for and take any required examinations.*

Yes
35. I understand that my credential will be issued after I earn a passing score on any required examinations.*

Yes
36. I understand that I am required to earn the credential within 12 months of application. If I fail to earn the credential in the 12-month period, I may request the option to pay a continuation fee to keep my application active.*

Yes
37. I understand that all Board fees are non-transferable and non-refundable.*

Yes
38. I believe that I am qualified for the level of certification for which I am applying, have submitted correct information in my electronic application, have sought supporting documentation from required sources, and expect to sit for the required examination(s) and hold the credential I am seeking within 12 months or less of application.*

Yes
Electronic Signature*

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National Certified Peer Specialist (NCPS)

Your Information

Mailing Address & Employment Information

Criminal Background

Formal Education

Supervised Work Experience

28. Add information about your eligible current or former supervisors

29. Add an additional eligible current or former supervisor

Content Specific Training

Professional Recommendations

Attestations