APPLICATION FORM FOR NATIONAL CERTIFIED PEER RECOVERY SUPPORT SPECIALIST I. Personal Data Name: Address: City/State/ZIP+4: Phone: (w) / (h) / (f) / E-mail: Employer: NAADAC ID #, if applicable: Credential Payment/Fee Information NCPRSS $235.00 Amount Enclosed: $.00 Credit card amount: $.00 (check/money order payable to NCC AP) Company card Personal card MasterCard Visa America Express Credit Card number / Expiration Date Card holder s signature Card holder s name (please print) Page 1 of 9
II. Certification Eligibility & Application Requirements NATIONAL CERTIFIED PEER RECOVERY SUPPORT SPECIALIST Eligibility Requirements GED, High School Diploma, or higher. Current credential or license issued by a state or credentialing authority, if applicable. Minimum of one year full-time of direct practice (volunteer or paid) in a peer recovery support environment. At least 60 contact hours of peer recovery focused education and training to include education in documentation, community/family education, case management, crisis management, Recovery-Oriented Systems of Care (ROSC), screening and intake, identification of indicators of substance use and/or co-occurring disorders for referral, service coordination, service planning, cultural awareness and/or humility, and basic pharmacology. Must include a minimum of six hours of ethics and six hours of HIV/bloodborne pathogens training within the last six years. At least 50% of training hours must be face-to-face. Minimum two years of recovery from Substance Use/Co-Occurring Mental Health Disorders (self-attestation). Passing score on the NCPRSS examination within four years of the application. Application Requirements A copy of GED, High School or higher diploma or transcript. Evidence of current credential or license issued by a state or credentialing authority, if applicable. Confirmation of a minimum of one year full-time of direct practice (volunteer or paid). Evidence of minimum of 60 contact hours of peer recovery focused education and training to include education in documentation, community/family education, case management, crisis management, Recovery-Oriented Systems of Care (ROSC), screening and intake, identification of indicators of substance use and/or co-occurring disorders for referral, service coordination, service planning, cultural awareness and/or humility, and basic pharmacology. Must include a minimum of six hours of ethics and six hours of HIV/bloodborne pathogens training within the last six years. At least 50% of training hours must be face-to-face. Confirmation of minimum two years of recovery from substance use/co-occurring mental health disorders (self-attestation), if applicable. Two references (at least of one of which is professional) to be submitted in sealed envelopes. Submission of a signed statement that the candidate has read and adheres to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics. NOTE: A passing score on the National Certified Peer Recovery Support Specialist examination is required. Registration information for the examination will be provided once your endorsement application is approved. Page 2 of 9
III. Education Record Training Hours Summary: Please attach copies of all training events (college transcripts, conference/seminar attendance certificates, and/or any other continuing education credits). Please Note: Graduate level hours, if applicable (transcript required) Undergraduate hours, if applicable (transcript required) Other training hours (CE Certificates required) Total hours (60 CE requirement) Ethics trainings hours in last six years HIV/bloodborne pathogens training hours in last six years Please Check Boxes to Confirm Documented Training Hours in the Following Areas: Documentation Community/Family Education Case Management Crisis Management Recovery-Oriented Systems of Care (ROSC) Screening and Intake Identification of Indicators of Co-Occurring Disorders for Referral Service Coordination Services Planning Cultural Awareness or Humility Basic Pharmacology Page 3 of 9
IV. Career History In providing your employment history, please list your current position first and work backwards until you have documented the required minimum of one year of full time direct practice in a peer recovery support environment (volunteer or paid). Attach additional pages as needed. Current Employer: Address: Job/volunteer title: Position held from (month/year) to (month/year) Supervisor: Please Print ( ) - Telephone Brief job/volunteer description: Page 4 of 9
Employer: Address: Job/volunteer title: Position held from (month/year) to (month/year) Supervisor: Please Print ( ) - Telephone Brief job/volunteer description: Page 5 of 9
V-a. Confirmation of Recovery (Self-Attestation) I verify having a minimum of two years of recovery from Substance Use/Co-Occurring Mental Health and Substance Use Disorders. Applicant s Signature Applicant s Name (please print) Date ( ) - Telephone V-b. Direct Practice Confirmation (Self-Attestation) I verify having a minimum of one year of full-time direct practice in a peer recovery support environment (volunteer or paid). Applicant s Signature Applicant s Name (please print) Date ( ) - Telephone VI. Candidate s Affirmation I certify that I meet the eligibility requirements for the National Certified Peer Recovery Support Specialist (NCPRSS) national credential, and that the information in this application and its supporting documents is accurate, correct and complete. I also certify that the state credential/license presented is not encumbered in any manner and that I do not hold a credential/license from any other state that is or has been subject to criminal or ethical complaint. The National Certification Commission for Addiction Professionals (NCC AP) is authorized to contact any institution, organization or individual listed on or included with this application for verification of my substance use disorders counseling history. I understand that the NCC AP retains ownership of the NCPRSS certificate and may, from time to time, make available endorsement holder names and other information to potential service users. Candidate s Signature/Date: Note: State licensure/certification is required for the NCPRSS credential, if applicable. Page 6 of 9
Preamble National Certified Peer Recovery Support Specialist (NCPRSS) Code of Ethics The NAADAC/NCC AP National Certified Peer Recovery Support Specialist (NCPRSS) Code of Ethics outlines basic values and principles of peer recovery support practice. This Code serves as a guide for - responsibility and ethical standards for NCC AP National Certified Peer Recovery Support Specialists. Peer Recovery Support Specialists have a responsibility to help persons in recovery achieve their personal recovery goals by promoting self-determination, personal responsibility, and the empowerment inherent in selfdirected recovery. Peer Recovery Support Specialists shall maintain high standards of personal conduct, and conduct themselves in a manner that supports their own recovery. Peer Recovery Support Specialists shall serve as advocates for the people they serve. Peer Recovery Support Specialists shall not perform services outside of the boundaries and scope of their expertise, shall be aware of the limits of their training and capabilities, and shall collaborate with other professionals and Recovery Support Specialists to best meet the needs of the person(s) served. Peer Recovery Support Specialists shall preserve an objective and ethical relationship at all times. This credential does not endorse, suggest or intent that a Peer Recovery Support Specialist will serve independently. The Peer Recovery Support Specialist shall only work under supervision. I. Conduct As a Peer Recovery Support Specialist, I will: 1. Agree to maintain a minimum of two (2) clinical supervision sessions per month totally at least 2 hours of documented clinical supervision. 2. Accurately identify my qualifications, expertise, and certifications to all whom I serve and to the public. 3. Conduct myself in accordance with the NCC AP NCPRSS Code of Ethics. 4. Make public statements or comments that are true and reflect current and accurate information. 5. Remain free from any substances that affect my ability and capacity to perform my duties as a Peer Recovery Support Specialist. 6. Recognize personal issues, behaviors, or conditions that may impact my performance as a NCPRSS. 7. Maintain regular supervision and ongoing support so I have a person with whom I can address challenging personal issues, behaviors, or conditions that may negatively effect my own recovery. I understand that misconduct may result in the suspension of my credentials. 8. Respect and acknowledge the professional efforts and contributions of others and not declare or imply credit as my own. If involved in research, I shall give credit to those who contribute to the research. 9. Maintain required documentation for and in all client records as required by my agency or the Federal requirements making certain that records are documented honestly and stored securely. Agency disposal of records policies shall be adhered to. 10. Protect the privacy and confidentiality of persons served in adherence with Federal Confidentiality, Page 7 of 9
HIPPA laws, local jurisdiction and state laws and regulations. This includes electronic privacy standards (Social Media, Texting, Video Conferencing etc). 11. Use client contact information in accordance with agency policy. 12. Not to create my own private practice. II. Conflict of Interest As a Peer Recovery Support Specialist, I will: 13. Reveal any perceived conflict of interest immediately to my professional supervisor and remove myself from the peer recovery support specialist relationship as required. 14. Disclose any existing or pre-existing professional, social, or business relationships with person(s) served. I shall determine, in consultation with my professional supervisor, whether existing or preexisting relationships interfere with my ability to provide peer support services person(s) served. 15. Inform clients of costs of services as established by the agency for which I am employed and not charge person served beyond fees established. 16. I will not sponsor individuals with whom I have previously served or currently serve as a Peer Recovery Support Specialist. III. Support Specialist/Client Relationship As a Peer Recovery Support Specialist, I will: 17. Clearly explain my role and responsibilities to those serve. 18. Terminate the relationship with a person(s) served when services appear no longer of benefit and to respect the rights of the person served to terminate services at his/her request. 19. Request a change in my role as a NCPRSS with a person being served if the person served requests a change. 20. Not engage in sexual activities or personal relationships with persons served in my role as a NCPRSS, or members of the immediate family of person(s) served. 21. Set clear, appropriate, and culturally sensitive boundaries with all persons served. 22. If at any point I feel I am unable to meet any of these requirements, I will immediately cease performance as a Peer Recovery Support Specialist and seek professional assistance. I hereby attest that I have read, understand, and will adhere to the NAADAC/NCC AP NCPRSS Code of Ethics, as described above. Printed: Signature: Date: Page 8 of 9
Candidate s Checklist Completed Personal Data Included check/money order or provided credit card information (The NCC AP has a no refund policy for incomplete applications.) Enclosed copy of GED, High School or higher diploma or transcript. Enclosed copy of certification or license issued by a state or credentialing authority, if applicable. Completed Education Section Completed Career History Section Candidate s Recovery and Direct Practice Confirmations (V-a. and V-b.) Completed Candidate Affirmation Education/Training Certificate Copies (to include six hours of Ethics & six hours of HIV/bloodborne pathogens training within the last six years) Signed and notarized statement that candidate has read, understands, and will adhere to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics Two letters of reference (one must be professional) in sealed envelopes Application and supporting documentation must be mailed to the address below. NCC AP - Certification Department 44 Canal Center Plaza, Suite 401 Alexandria, VA 22314 Page 9 of 9