Fillable Knowledge/ Skill Exams (Pennsylvania Certification Board)

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Knowledge/ Skill Exams (Pennsylvania Certification Board)

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PCB CIP Application | Revised January 2021
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to applying, all requirements must be met and documented.
Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not
indicate it has been received. To confirm receipt of application, email info@pacertboard.org
.
REVIEW & APPROVAL PROCESS
1. Application submitted to PCB. To confirm receipt of application, email PCB at the above email address.
2. Staff reviews application. Allow up to 10 business days for review and processing.
3. Applicant will be emailed if there is any documentation missing or there are questions regarding an
application. Applications with pending problems will be held open for one year from date of receipt
after which they will be closed.
4. If you have not heard from PCB regarding your application after 10 business days, email
info@pacertboard.org
.
5. A certificate will be mailed to you within 10 business days.
CIP APPLICATION
Certified Intervention Professional
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
2
CERTIFIED INTERVENTION PROFESSIONAL REQUIREMENTS
All requirements below must be met to apply. All required documentation must be sent in with an application
except for the official college transcript which is sent to PCB directly prior to application.
FORMAL EDUCATION
REQUIRED: Minimum high school diploma/GED.
Veterans may provide discharge documentation in lieu of a high school diploma/GED.
A copy of the high school transcript or diploma is acceptable or GED verification. If the school is from outside the
United States, an equivalency must be done by an organization that specializes in that process. The applicant is
responsible for arranging this process and all costs.
It is recommended you obtain documentation approximately three weeks prior to sending in your application.
Documentation of high school/GED can be included with your application or can be mailed to PCB or emailed
to info@pacertboard.org
by the educational institution prior to application.
College degree documentation can be used in lieu of a high school diploma/GED. The degree must be from an
accredited college/university that is recognized by the US Department of Education or the Council on Higher
Education Accreditation. An official transcript sent directly from college/university is required. If the degree is
from outside the United States, a degree equivalency must done by an organization that specializes in that
process. The applicant is responsible for arranging this process and all costs.
Official transcripts are required and must be sent directly from college/university to PCB prior to application.
Official transcripts may be mailed to PCB or emailed to info@pacertboard.org
.
It is recommended you request transcripts approximately three weeks prior to sending in your application.
If you have a sealed official transcript in your possession, you may mail it in the sealed envelope to PCB prior to
your application arriving or mail it in with your application.
If you have outstanding debt or other issues which prevent the college/university from releasing your official
transcript, you must resolve these issues with the school prior to applying for certification.
WORK EXPERIENCE
REQUIRED: Two (2) years of full-time or 4000 hours of part-time work experience providing
direct substance use intervention and related services at least 50% of the time.
Qualifying work experience is defined as professionals who have the primary role of facilitation and
participation in substance use interventions. Intervention professionals guide families, friends, and others
through an intervention process where the substance user is encouraged to accept help. They are trained and
skilled in family systems and successful intervention techniques. The interventionist supports, educates,
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
3
provides guidance, direction, and training, as well as the facilitation of the intervention and aftercare. Examples
of positions that typically are not approved include counselors, marketers, recruiters, case managers,
technicians, peer and recovery counselors/specialists, intake, admissions, etc. No other work experience in the
drug and alcohol field can be used for intervention professional certification other than what is stated above.
Qualifying work experience can be from multiple employers to accumulate the required years/hours.
If the applicant’s work experience requirement is not fulfilled from their current employer, they must include
documentation from previous employer(s) verifying their title, duties and dates employed with their
application. DO NOT submit a resume as proof of previous work experience. Applicant must contact previous
employers and request detailed documentation of their employment from them.
The applicant must be currently employed as an intervention professional at the time of application.
All work experience must have occurred within the last seven (7) years. Volunteer work is not acceptable. Time
spent participating in or facilitating mutual support groups is not acceptable.
Clinical internships completed as part of a college degree program may be eligible to use toward the required
work experience. Internships must be ones in which the student was providing drug and alcohol counseling as
described on page 10 of this application under Work Experience; internships must be well documented by the
agency in which the internship occurred; internships must have been supervised; internships must appear on
the official college transcript.
CURRENT JOB DESCRIPTION
REQUIRED: Copy of current interventionist job description, obtained from current
employer, and which must be signed by both the applicant and their immediate supervisor.
All applicants must include a copy of their current interventionist job description. This document is provided by
your employer and must be signed and dated by the applicant and their immediate supervisor.
Job descriptions determine and verify eligible current work experience. Job description must clearly delineate
substance use interventions as a primary function of the position.
In lieu of job description(s), employer may provide an official position description on agency letterhead. This
required documentation must include the applicants’ dates of employment (to/from) employment status (full-
time or part-time), title of position, a detailed description of the duties and responsibilities for the position, and
the average number of hours per week the applicant worked.
ON-THE-JOB SUPERVISION
REQUIRED: 100 hours of on-the-job supervision of qualifying work experience with a
minimum of 10 hours of supervision in each intervention domain.
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
4
Supervision is a formal or informal process that is evaluative, clinical, educative, and supportive. It ensures
quality of clinical care and extends over time. Supervision includes observation, mentoring, coaching, evaluating,
inspiring, and creating an atmosphere that promotes self-motivation, learning, and professional development. In
all aspects of the supervision process, ethical and diversity issues must be in the forefront.
PCB has no requirements for who provides supervision. The person providing clinical supervision is at the
discretion of the agency.
Supervision can be provided in an individual, one-on-one setting and/or observation of skills or group
supervision setting.
Supervision can be provided by more than one supervisor. In this case, provide a copy of page 11 of this
application to all the supervisors documenting supervision on your behalf.
EDUCATION/TRAINING
REQUIRED: 150 hours of relevant education/training to include 20 hours in intervention
theory and practice; 12 hours in family systems; 12 hours in motivational interviewing; 12
hours in addiction; 6 hours in crisis intervention; 6 hours in behavioral health ethics.
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-services,
college/university credit courses, and online education.
There is no limit to the amount of online education that may be submitted.
Most three-credit college/university courses count as 45 hours. One training CE/CEU counts as one hour.
All education/training must be documented. College courses are documented with an official college transcript.
Trainings are documented with copies of training certificates.
Training certificates must have the applicant’s name, title of training, date(s) of training, the number of hours
being awarded, and the name of training organization. Training certificates submitted without this required
information on them will not be accepted.
If a training title on a certificate of attendance does not clearly indicate the education content, attach a copy of
the training description.
Training registration forms and/or training sign-in sheets are not acceptable forms of documentation.
Training must be non-repetitive meaning the same training cannot be claimed more than one time even if the
training is taken on different dates from different providers.
Official employer training tracking system/learning management system reports may be acceptable forms of
documentation for education/training provided that the report contains the name of the employee/applicant,
titles of each training, dates of each training, the number of hours of each training, and is signed by the
applicant’s supervisor.
There is no time limit on when the education/training was received.
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
5
INTERVENTIONS
REQUIRED: Participation in five (5) interventions and facilitation of five (5) interventions
within the last three (3) years for a total of ten (10) interventions.
Interventions are documented on pages 9 and 10 of this application.
PORTFOLIO
REQUIRED: Submission of all three mandatory categories and one optional category below.
A portfolio is a collection of personal and professional activities and achievements. This part of the requirement for
the CIP is highly personalized and no two applicants will submit the same documentation.
An applicant will fulfill this requirement by submitting documentation and requirements of the first three
mandatory categories and at least one (1) optional category for a total of four (4) categories. Multiple submissions in
one category will only count as fulfilling one (1) of the four (4) required. Supporting documentation can include
reports, letters, PowerPoint presentations, transcripts, etc. The applicant should submit what they feel best
supports and describes their experiences under their chosen categories. When selecting a category and submitting
the documentation, the intervention professional should use the opportunity to highlight the value and
commitment to the profession.
Mandatory categories (must submit all of three.)
1. Narrative on intervention modality: a variety of intervention modalities are available to
interventionists. Applicants must submit an essay of no less than 1000 words describing the primary
modality they use. If more than one modality is used, please spend equal time describing them. A
reference list must be submitted with the narrative. In text citations are not required.
2. Statement of professional experience: applicants must submit an essay of no less than 1000 words
responding to the following questions:
A. Describe a success story in your role as an interventionist and what resources (systems,
agencies, etc.) Have you helped people connect to? How did you apply training as an
interventionist to this experience?
B. Describe your areas of expertise related to intervention.
C. Describe strengths and opportunities for improvement in your professional life.
D. Describe your motivation to work in the field of intervention.
3. Performance evaluation: applicants can choose two or more of the areas listed below. Evaluations
should highlight the applicant’s abilities as an interventionist and must be completed within two years
prior to the application date. Evaluations must be sent directly to PCB via email or mail from the person
or organization.
A. Copy of an agency evaluation.
B. Statement from supervisor or colleague evaluating the interventionists performance.
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
6
C. Reference letter received from an organization in the behavioral health field that you have
worked with. You may not be a current, previous, or contracted employee of said organization.
The letter must be on organization letterhead.
Optional categories (must choose one.)
1. Mentorship: applicants must submit three letters from a previous mentor(s) and/or mentee(s). The
letters may be from mentors or those you have mentored but may also be a combination of the two.
2. College level courses/advanced or specialized training: applicants that complete coursework relevant
to the CIP domains, in addition to the 150 hours, must submit documentation and a summary of the
coursework. Coursework in this category must be completed within the last two years prior to the date
of application. Acceptable forms of coursework include:
A. College course: degree does not need to be completed for the course to count
B. Advanced/specialized training: training can be in multiple topics. Must total 30 hours.
3. Publications, presentations & projects: applicants who have completed three or more of the following
should submit documentation (i.e.: copy of completed brochure, event announcement, promotion
materials) and a summary of their participation.
A. Authored/co-authored books
B. Newsletters to the community
C. Abstracts
D. Poster presentations
E. Curriculum, training development and facilitating trainings
F. Resource guide development
G. Community programming/workshops
H. Spotlight or participation on intervention specific tv, radio, social media, websites, etc.
I. Community event organization and participation
CERTIFICATION FEE
REQUIRED: $300.00
(fee must accompany certification application)
The fee may be paid by check, money order or with VISA, MasterCard, Discover or American Express.
If an employer or organization is paying the fee, they must include the applicants name with the payment.
Fee payment information provided on page 8 of this application. E-receipts will be sent if using a credit card for
payment. Receipts for check or money order payments must be requested by applicant to PCB.
Applications received without payment will not be processed.
One-half of the fee is refundable if application is denied.
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
7
APPLICATION INFORMATION
GENERAL INFORMATION
Email addresses provided to PCB must be active accounts that are checked regularly. We will not be able to contact
you without an email address. Please print legibly.
APPEAL PROCESS
The purpose of appeal is to determine if PCB accurately reviewed an application that is denied. A letter
requesting an appeal must be sent to PCB within 30 days of the notification of PCB's action. An applicant shall be
considered notified three days after the relevant date of mailing. The appeal will be sent to the PCB Executive
Committee who will thoroughly review the entire application and materials to determine whether or not
applicant should have been denied approval. The applicant will be notified in writing as to the findings of the
Executive Committee.
FELONIES & DISCIPLINARY ACTIONS
While felonies and disciplinary actions from other certification/licensing entities may not prohibit certification,
documentation is required to be submitted at the time of application. Certification through PCB does not mean
a professional should not disclose this information to potential employers and does not in any way exonerate
charges.
REQUESTS TO CHANGE APPLICATION
Professionals who wish to have their application re-reviewed for another credential PCB offers prior to taking
the examination or after an unsuccessful attempt at the examination will incur a $50 application change/review
fee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the applicant passes the examination. The
certificate issued to the professional lists the following information: name of professional, credential name, date
of issue, date of expiration and certification number.
RECERTIFICATION
To maintain the high standards of professional practice and to assure continuing awareness of new knowledge
in the field, the Board requires recertification every two years. Professionals should review the Recertification
Application for credential specific requirements listed on the Board website well in advance of their expiration
date.
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
8
CIP APPLICANT INFORMATION & PAYMENT
Application can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
Date:
DOB:
□ Female
□ Male
□ Self-identify _____________________
Name:
SSN: (last four)
Print your name as it should appear on your certificate. Credentials and degrees will not be printed.
Home Address:
City:
State:
Zip:
Cell Phone:
Primary Email:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
Secondary Email:
PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
Have you ever received any disciplinary action from another certification/licensing authority? □ Yes □ No
If yes, provide full details on a separate sheet.
Have you read and understood the PCB Code of Ethical Conduct? □ Yes □ No
The Code of Ethical Conduct is located at www.pacertboard.org, and click on Ethics.
Military Experience: □ Not Applicable □ Active □ Veteran
Ethnicity: □ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic □ Latino
□ Native Hawaiian or Other Pacific Islander □ Not specified: ______________________
Employment plans for the next two years: □ Increase hours □ Decrease hours □ No change □ Seek advancement
□ Retire □ Move to a different career □ Unknown
PAYMENT INFORMATION
FEE OF $300 CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
□ My employer/organization is mailing payment directly to PCB.
Email for receipt (if paying by credit card only): ________________________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
9
CIP: FORMAL EDUCATION & TRAINING
REQUIRED: Minimum high school diploma/GED.
I am documenting my high school diploma/GED.
□ Yes □ No
I am documenting my college degree.
□ Yes □ No
College/University:
Name on Transcript:
Date Transcript Requested:
Delivery Method:
□ Mailed to PCB
□ Emailed to PCB
REQUIRED: 150 hours of relevant education/training to include 20 hours in intervention theory and
practice; 12 hours in family systems; 12 hours in motivational interviewing; 12 hours in addiction; 6
hours in crisis intervention; 6 hours in behavioral health ethics.
I have included copies of training certificates.
□ Yes □ No
I have included a copy of my training tracking system/learning management system report.
□ Yes □ No
My college transcript provides some or all of the relevant education.
□ Yes □ No
Education Checklist
CATEGORY
NUMBER OF
HOURS
DOCUMENTATION TYPE
(certificate of attendance, system report,
transcript)
Relevant (at least 82 hours)
Intervention Theory and Practice (20 hours)
Family Systems (12 hours)
Motivational Interviewing (12 hours)
Addiction Specific (12 hours)
Crisis Intervention (6 hours)
Behavioral Health Ethics (6 hours)
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
10
CIP: WORK EXPERIENCE & JOB DESCRIPTION
REQUIRED: Two (2) years of full-time or 4000 hours of part-time work experience providing direct
substance use intervention and related services at least 50% of the time.
REQUIRED: Copy of current interventionist job description, obtained from current employer, and
which must be signed by both the applicant and their immediate supervisor.
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Total hours/years worked in current position? ___________________________________________________________
I have attached my current counselor job description, dated, and signed by both me and my supervisor. □ Yes □ No
Do you need to document previous employment to fulfill the experience requirement? □ Yes □ No
If yes, complete the section below AND submit a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed
must be included with your application.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE)
Letter (on company letterhead) from previous employer(s) verifying your title, duties & dates employed must be included with your application.
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
11
CIP: ON-THE-JOB SUPERVISION
REQUIRED: 100 hours of on-the-job supervision of qualifying work experience with a minimum of 10
hours of supervision in each intervention domain.
Information below is to be completed by applicant’s current and/or previous supervisor(s).
This page is to document the supervision hours provided to the applicant, not their total work hours.
The total hours of supervision should be 100 hours but could be more depending on the applicants’ length of
employment or could be less if the applicant was provided supervision from a previous employer.
Applicants may copy this page and provide it to previous supervisors.
Applicant Name:
SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
SUPERVISION DOCUMENTATION
Supervision was provided to the above-named applicant in the following Domains:
DOMAIN
EXACT NUMBER OF HOURS
□
Intervention Competence
□ Pre-Intervention
□ Intervention
□ Post-Intervention
□ Professional & Ethical Responsibilities
Supervisor Attestation:
I attest that the above-named applicant has been provided with supervision as documented above.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF SUPERVISION:
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
12
CIP: INTERVENTION DOCUMENTATION
I have participated in the following interventions:
Facilitator Name:
Email:
Phone:
Facilitator Name:
Email:
Phone:
Facilitator Name:
Email:
Phone:
Facilitator Name:
Email:
Phone:
Facilitator Name:
Email:
Phone:
I have facilitated the following interventions:
I attest that the above information is correct, and that PCB may contact the facilitator of an intervention to confirm
participation.
____________________________________________________
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
Date:
Location:
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
13
CIP: PORTFOLIO DOCUMENTATION
MANDATORY CATEGORIES
DOCUMENTATION TYPE
(letter, certificate of attendance,
system report, transcript, etc.)
INCLUDED IN APPLICATION
SUBMISSION (
✓)
Narrative on Intervention Modality
Statement of Professional Experience
Performance Evaluation
OPTIONAL CATEGORIES
(choose one)
DOCUMENTATION TYPE
(letter, certificate of attendance,
system report, transcript, etc.)
INCLUDED IN APPLICATION
SUBMISSION (
✓)
Mentorship
College Level Courses/Advanced or
Specialized Training
Publications, Presentation & Projects
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
14
CIP: ACKNOWLEDGEMENTS & RELEASE
This page must be completed by the applicant. It must be notarized and submitted with the application.
RELEASE
I request that the Pennsylvania Certification Board (PCB) grant the credential to me based on the following assurances
and documentation:
• I subscribe to and commit myself to professional conduct in keeping with the PCB Code of Ethical Conduct;
• I certify that the information given herein is true and complete to the best of my knowledge and belief. I also
authorize any necessary investigation and the release of information relative to my application;
• Falsification of any documents will nullify this application and will result in denial or revocation of certification;
• I consent to the release of information contained in my application and any other pertinent data submitted to or
collected by PCB to officers, members, and staff of the aforementioned Board;
• I consent to authorize PCB to gather information from third parties regarding education, employment and/or
supervision and understand that such communication shall be treated as confidential;
• Allegations of ethical misconduct reported to PCB before, during, or after application for certification is made
will be investigated by PCB and could result in the nullification of the application or denial or revocation of
certification.
INITIAL EACH STATEMENT
I have read and understood this Acknowledgements and Release.
I understand one-half of the application fee is refundable if application is denied.
I understand that my application is open for a period of one year after the date of review. If I fail to fulfill all
certification requirements within that year, the application will be closed, and no refund will be issued.
I understand that if I request to have my application re-reviewed for another credential PCB offers,
I will incur a $50 change/review fee.
Applicant:
Signature:
Date:
PRINT NAME LEGIBLY
NOTARY PUBLIC ONLY
Name:
Date:
I attest that I am a notary public and the above-named applicant satisfactorily proved to be the person whose name is
subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereby set my hand and official seal.
__________________________________________________ SEAL:
Notary Public Signature
PCB CIP Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
15
CIP: CHECKLIST
Applicant Name:
Page must be completed and submitted with the application. Do not submit your application until checklist is reviewed,
completed and all documentation is compiled.
Prior to applying, all requirements must be met and documented. Use the table below as a guide for gathering
documentation.
Do not submit any documentation with an application that is not listed on the table or the application
unless specifically instructed by a staff member. Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: PCB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: info@pacertboard.org NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not indicate it has been
received. To confirm receipt of application, email info@pacertboard.org
.
I acknowledge, that to the best of my ability, I have submitted a completed application.
Signature:
Date:
REQUIREMENT DOCUMENTATION
✓
Application page with payment
• Page 8
Formal Education page
• Page 9
Education
• High School Diploma/GED transcripts or diploma
•
Copies of training certificates (if applicable)
Work Experience
• Page 10
• Previous relevant employment documentation
(if needed)
Current job description
• Obtain from employer
Supervision page
• Page 11
Intervention documentation
• Page 12
Portfolio documentation
• Page 13
Notarized Acknowledgement & Release page
• Page 14
Checklist page
• Page 15
Disciplinary Actions?
• Include letter of explanation with application
Convicted of a felony?
• Include letter of explanation with application
Company paying fee?
• Include applicant name on payment
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Knowledge Skill Exams (Pennsylvania Certification Board)

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