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

Two-Year Recertification Instructions

Applications for recertification must include the following items. Be prepared to upload the documents with this form:
1. Complete this recertification application. This includes recertification documentation and signatures uploaded using this form.
2. Submission of signed and dated “Affirmation of Truth” included on this form.
3. Submission of signed and dated WVCBAPP Code of Ethics included on this form.
4. Submission of approved contact hour documentation totaling at least 40 clock hours of continuing education units (CEU), with a minimum of 6 hours in substance use or prevention specific studies. Six (6) hours of substance use or prevention specific ethics is REQUIRED to renew. The remaining hours can be in any combination of the following areas: substance use disorders, prevention technique/theory, and/or behavioral sciences. These CEUs must be dated within the last two years of this submission and attached to this form using the provided upload space.
5. CS Renewal only: 6 hours of clinical supervision.
6. Submission of non-refundable recertification fee due for each credential held and any late penalty fees (if applicable).
*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.

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, AADC, CS,CCJP, PSI, PSII Recertification Application

West Virginia Certification Board for Addiction and Prevention Professionals
Before You Begin the Application

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*

MonthDayYear
Date
Has any of the information below changed?*

YesNo
Name*

First Name Last Name
Maiden, Nickname, or Preferred Name:
Optional
Date of Birth *

MonthDayYear
Date
E-mail*
example@example.com
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Highest Education Level*
Certification Currently Held (select all that apply)*

PRSS-SUDPRSS-MHAADCADCPSI or PSIICCJPCSCSPRSSCSPRSS-CLOther
Which credential(s) are you renewing?:*

ADCAADCCSPSIPSIICCJP
License Currently Held:*

LPCLICSWBSWLSWMD/DOMFTRNLPNNot applicableOther
First Year of Employment in the SUD/Prevention Field:*
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Ethical Code of Conduct/Ethcis PSI and PSII

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 Prevention 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 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 Prevention 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.

AFFIRMATION OF TRUTH:

I hereby attest that I have read, understand, and will adhere to the IC&RC Code of Ethics 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.

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*

I agreeI disagree
Signature*

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Date*

MonthDayYear
Date
Ethics Certificate Upload: Six (6) hours of SUD/prevention specific ethics is REQUIRED to renew. These CEUs must be dated within the last two years of this submission.*

PSi and PSII are required to have prevention specific ethics uploaded here.
Cancelof
Substance Use Disorder or Prevention Specific CEUs: Upload minimum of six (6) hours in substance use or prevention specific studies here. These CEUs must be dated within the last two years of this submission*

PSI and PSII are required to have prevention specific uploaded here.
Cancelof
Certificate File Upload: Upload the remaining twenty-eight (28) contact hours of approved continuing education. These CEUs must be dated within the last two years of this submission.*

Cancelof
Supervision Certificate Upload for CS Renewal: Six (6) contact hours specific to clinical supervision are required. These CEUs must be dated witting the last two year of this submission.

Only applies to those renewing the Clinical Supervision Credential
Cancelof
How will you be paying the fee?*
Pay Fees via PayPal (non-refundable) DO NOT CHECK THE BOXES BELOW IF YOU ARE MAILING IN PAYMENT.
prevnext( X )
AADC Recertification FeeRecertification fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$189.00



ADC Recertification FeeRecertification fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$189.00



CCJP Recertification FeeRecertification fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$189.00



Clinical Supervison Recertification FeeRecertification 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 IRecertification fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$189.00



PS IIRecertification fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$189.00



Late/Rush Processing FeeInclude after 8/30 of your recertification year. This can also be paid on our website or via mail. All payments made via PayPal are charged an 8% processing fee.
$81.00



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:

ADC, AADC, CS,CCJP, PSI, PSII Recertification Application

Current Employment: