West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
436 12th Street, Suite C, Dunbar, WV 25064

304-768-2942
Individual Continuing Education Approval Form

This form is for certified individuals to utilize in getting approval for training that has not been approved through WVCBAPP by the sponsor of the training.
Date of Application*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title of Training Event:*
Sponsored By:*
Location of the Training:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EDUCATION TRAINING DESCRIPTION

Please read the "Knowledge and Skills", "Counselor Core Functions" or “Domains”.

Using the material designation indicate which will be emphasized in the training event. If you are applying for approval for an event which has several different sessions and presenters, please make multiple copies of the attached form.

Complete one form per session. The Continuing Education Committee requires that you submit this form with your re-certification application information, (certificate, etc.) documenting your attendance at each particular training.
How will you be paying the application fee?*

PayPal using this formPayPal on the WVCBAPP websiteCheck or Money order
Application Fee
prevnext( X )
Application FeePayPal payments have an 8% convenience fee. Check or money orders are accepted via mail.
$10.80

Total

$0.00
Education Training Description
Title of Session*
Date of Session*

MonthDayYear
Date
Session Objectives *
Knowledge & Skills Emphasized *
Certification Core Functions Emphasized *
Instructors Credentials *
Other Information Useful in Evaluating Training
Number of Contact Hours*
60 minutes =1 contact hour
Domains

Check all of the domains covered in the reported training
Counseling Domains:*

Screening, Assessment, and EngagementTreatment Planning, Collaboration, and ReferralCounseling and EducationProfessional and Ethical ResponsibilitiesN/A
Prevention Domains*

Planning and EvaluationPrevention Education and Service DeliveryCommunicationCommunity OrganizationPublic Policy and Environmental ChangeProfessional GrowthN/A
Peer Recovery Support Specialist Domains*

AdvocacyMentoring/EducationRecovery and Wellness SupportEthical ResponsibilityN/A
Upload Training Information *

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I hereby attest that all information provided in this application is true and valid to the best of my knowledge.
Signature of the supervising credentialed entity:*

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West Virginia Certification Board for Addiction and Prevention Professionals

Education Training Description

Domains