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

ADC Initial Certification Instructions

Applications for ADC certification must include the following items. Be prepared to upload the documents with this form:
1. Signed and dated “Affirmation of Truth” (notary form). Available at www.wvcbapp.org forms.
2. Photo ID.
3. Updated resume.
4. Signed and dated WVCBAPP Code of Ethics.
5. Supervised experience fully signed by applicant and supervisior(s).
6. Education contact hours documentation totaling at least 300 clock hours of continuing education units (CEU), with a minimum of 70 hours in substance use, recovery, or prevention specific studies.
7. Six (6) hours of the 70 SUD-specific CEUS must be in ethics.
  - 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 categorized and uploaded to this form.
8. Submission of non-refundable application review and exam fee.
9. Send official transcripts to wvcbapp@wvcbapp.org. Unofficial transcripts can be uploaded, but approval to test requires official.
*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. This will delay the application reivew up to 30 days.

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 Initial Certification Application

Use this for to apply for the ADC credential for the first time.
Before You Begin the Application

Read the enitre ADC manual.

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 of Initial Application*

MonthDayYear
Date
Demographics
Name*

First Name Last Name
Maiden, Nickname, or Preferred Name:
Optional
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residency Requirement: Initial applicants must live or work in West Virginia at least 51% of the time to qualify. This does not apply to recertification.*

YesNo
Date of Birth *

MonthDayYear
Date
E-mail*
example@example.com
Phone Number*
Upload Photo ID*

Required for test registration
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Certification Currently Held (select all that apply)*

PRSS-SUDPRSS-MHAADCADCPSI or PSIICCJPCSCSPRSSCSPRSS-CLNONEOther
License Currently Held:*

LPCLICSWBSWLSWMD/DOMFTRNLPNNot applicableOther
Are you in private practice?*

YesNo
First Year of Employment in the SUD/Prevention Field:*
Work Experience
Candidates must have a total of six (6) years of qualifying experience, which can be met through a combination of direct SUD-related work experience and general work experience:

• Addiction-Specific Work Experience: At least three (3) years (6,000 hours) of direct work experience in the substance use disorder field. Additional time in this category can be applied toward the total six-year requirement.

• General Work Experience: Up to three (3) years of general work experience may count toward the six-year requirement.

Candidates with higher education in a related field may substitute education for part of the work experience requirement:

• High School Diploma: 6,000 hours (3 years required) of SUD-specific supervised work experience.

• Associates degree: 5,000 hours (2.5 years required); may replace up to 1,000 hours of work experience.

• Bachelor’s Degree: 4,000 hours (2 years required); may replace up to 2,000 hours of SUD-specific experience.

• Master’s Degree or Higher: 2,000 hours (1 year required); may replace up to 4,000 hours of SUD-specific experience.

A maximum of four (4) years of college/university coursework in a related field may be applied toward the six-year (6) requirement.

Unsupervised work experience and/or PRSS experience does not qualify.
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Supervisor's Name*
Supervisor's Email*
example@example.com
Date of Hire*

MonthDayYear
Date
Is your current employment status?*

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your current job duties:*
Current Resume *

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SUD-Specific Former Employment:

Only List SUD-Specific Employment
Former Employer 1
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your job duties:
Former Employer 2
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your job duties:
Former Employer 3
Position
Supervisor's Name
Supervisor's Email
example@example.com
Date of Hire

MonthDayYear
Date
End Date

MonthDayYear
Date
What was your employment status?

Full-time more than 36 hours+ per weekPart-time less than 36 hours per week
Describe your job duties:
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional Former Employer 4
If you need more former employers to meet your work experience time, enter in the open text box the following information: Former employer's name, your position, supervisor's name and email, your date of hire and end date, description of duties, and full-time or part time status.
Optional Former Employer 5
Ethics
Ethical Code of Conduct

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 ADC.

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 ADC 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 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
Upload Completed Affirmation of Truth (notary form)*

Available at www.wvcbapp.org Be sure to use the ADC/AADC form
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Education & Training
To meet the 300 contact hour training requirement, you must provide proper documentation for all training hours.

1. Certificates of Attendance:

• You must upload copies of certificates of attendance for all training hours.

2. College Coursework:

• If using college courses to meet training requirements, an official transcript must be sent directly from the institution to the Board office.

3. SUD-Specific Training:

• Out of the 300 required contact hours, at least 70 hours must be specific to substance use counseling.

• 6 of these 70 hours must focus on ethics in substance use counseling.

4. Online Continuing Education Units (CEUs):

• You cannot claim more than 12 online CEUs in a single 24-hour period.
- You must sort your hours into the follow categories.
Ethics Certificate Upload: Six (6) hours of SUD/prevention specific ethics is REQUIRED to apply.*

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Substance Use Disorder or Prevention Specific CEUs: Upload minimum of seventy (70) hours in substance use or prevention specific studies here.*

You may have more than 70 hours of SUD-specific CEUs.
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Certificate File Upload: Upload the remaining twenty-eight (224) contact hours of approved continuing education. *

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Upload Unofficial Transcripts

Optional
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Highest Education Level*
Have your official transcripts been sent directly to the Board office?*

YesNo
What was your legal name at the time of your graduation?*
Used to pair the official transcripts to the application.
Provide the name of the institution from which your official transcripts are being sent.*
Name of high school/GED or college
Supervision Experience
Supervision Requirements

A college practicum/internship in a human services field may be used to fulfill supervision requirements but is not mandatory.

An example of a revisable supervision form and log in sheet is under the forms section of www.wvcbapp.org.

The supervised experience consists of hands-on work during which the applicant receives required supervision hours from a qualified supervisor:

•ADC-S, AADC-S, or AADC must provide at least 50% of this supervision.

• ADC without a CS credential may NOT supervise the SPE.

• Other supervisors must be licensed or credentialed in a human services field to qualify and can only provide 50% of the supervsion.

The required amount of supervision varies based on the applicant’s level of education:

High School Diploma or Equivalent =300 Hours
Associate Degree in a Related Field=250 Hours
Bachelor Degree in a Related Field=200 Hours
Masters Degree or Higher in a Related Field=100 Hours

Required Documentation

To ensure compliance with certification standards, applicants must document the followng:

1. Start and end dates of the supervised work experience.

2. Total hours completed and the credentials of the supervisor (ADC-S, AADC-

S, or AADC).

3. Defined Learning Goals:

• Goals must demonstrate that at least 10 hours of experience were completed in each of the domains.

• Goals should be specific to substance use knowledge areas as outlined in the certification manual’s

• These goals should clearly describe what was learned during the supervision.

• Learning goals may be developed by the applicant alone or with their supervisor.

• Both the applicant and supervisor must sign the form.

• Letters of reference from a work supervisor do NOT replace the required supervision documentation.

4. Methods Used (Tasks & Behaviors Performed):

• Document the specific tasks and professional activities performed in each domain.

See the ADC manual for more details.
Upload Signed Supervision Documentation *

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Application Review and Exam Fee

Non-refundable
How will you be paying the fee?*
Pay Fees via PayPal (non-refundable). This section is optional. DO NOT CHECK THESE BOXES IF YOU ARE NOT PAYING USING THIS FORM!
prevnext( X )
ADC Application FeeCertification application fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$81.00

ADC Exam FeeADC exam fee can be paid here, on our website, or via mail. All payments made via PayPal are charged an 8% processing fee.
$216.00

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 Initial Certification Application

Demographics

Work Experience

Current Employment:

SUD-Specific Former Employment:

Ethics

Education & Training

Supervision Experience

Application Review and Exam Fee