Self Attestation
Statement describing your pathway to recovery/wellness
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Provide information on how you achieved and maintain your recovery/wellness: Answers to the statements below MUST fill up an entire page of paper per PCB requirements.
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State how and why you feel that you are ready and appropriate to support others in a similar situation. Answers to the statements below MUST fill up an entire page of paper per PCB requirements.
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Submit
Should be Empty: