Self-Reporting Policy & Form

Status Change Form

Use this form to request reinstatement of active status after a self-report.
WEST VIRGINIA CERTIFICATION BOARD FOR ADDICTION AND PREVENTION PROFESSIONALS

A request for reactivation shall be considered at the next regularly scheduled meeting of the WVCBAPP board of directors. The applicant shall be notified of the board’s decision within two (2) weeks of the board’s meeting.
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Status *
Credential(s) Held:*

PRSS-MHPRSS-SUDAADCADCPSIPS2CCJPNone of the above (applicant)CSCSPRSSCSPRSS-CLOther
Date of Self-Report*

MonthDayYear
Date
Date of Incident *

MonthDayYear
Date
Company, organization, or employer at the time of the reoccurrence of symptoms: *
If unemployed, enter NA
Current company, organization, or employer*
If unemployed, enter N/A
Current Supervisor's Name

First NameLast Name
Current Supervisor's Email
example@example.com
Were clients involved in this situation? *
Plan of Action Progress
Location and Date of Completed Treatment*
Enter N/A if treatment was not included in the plan.
Description of change of circumstances allowing safe reentry to practice*
List and describe the supporting documents you will provide with your submission. Describe any past and/or future actions you will take to address the situation (trainings, attended or attending meetings, sponsor work, treatment, additional support through your supervisor or employer, any agreements with the court system or law enforcement): *
Upload the Documents Listed Above:*

Cancelof
If law enforcement is involved, what is the status of the investigation?*
Enter N/A if not applicable
Non-Refundable Status Change Fee
prevnext( X )
Status Change FeeYou may pay the fee using this form. This does have an 8% fee. If you wish to pay by check, please make the check payable to WVCBAPP and mail to the office.
$27.00

Total

$0.00
I attest that the information contained herein is true and correct. I will accept any requirements of the WVCBAPP.*

I agreeI disagree
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Status Change Form

Plan of Action Progress