Fillable Missouri Credentialing Board APRIL 30, 2021 RENEWAL FORMS (Missouri Credentialing Board)

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Missouri Credentialing Board APRIL 30, 2021 RENEWAL FORMS (Missouri Credentialing Board)

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CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 1
April 30, 2021 Renewal Instructions
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
APRIL 30, 2021 RENEWAL FORMS FOR
BIP, CCDP, CCDP-D, CCJP, CGDC, CHW-C, CPS, CRPR, CRPR-L, CRPS, MAPS,
MARS, MPS, MRSS, RADC, SQI, SQI-R, SQP and SQP-R
NOTICE: Check the MCB Professional Search on the MCB web site at www.missouricb.com for your new
expiration date(s) to determine if your renewal materials have been reviewed and are complete. If there is a
problem with your renewal, it will be addressed to you at the email address you listed on your renewal forms.
PLEASE READ THE RENEWAL INSTRUCTIONS IN THEIR ENTIRETY BEFORE COMPLETING
RENEWAL FORMS. THERE MAY BE DIFFERENT REQUIREMENTS FOR PROFESSIONALS
RENEWING FOR THE FIRST TIME.
If this is the FIRST time renewing your credential and you have a question on how many contact hours
you need to renew, please do the following:
1. Refer to the letter the MCB sent you when you received your initial credential.
First time renewal hours are individualized based on the time of year in which you initially received your
credential and other credentials held and therefore will vary between credentialed professionals.
All renewals MUST submit a copy of their Ethics Training; however only send in all training certificates if
your name was part of the April 2021 Renewal Audit. You can check the MCB website to see if your name
was randomly selected for the audit.
EDUCATION HOURS
Outside Education Hours:
Outside education is any continuing education related to one or more of the performance domains such as
workshops or seminars presented in a formal classroom setting, applicable college coursework, MCB self-study
course, or home study or online courses provided by a MCB pre-approved home study or online provider and
outside alcohol and drug trainings that you taught. Visit the MCB website at www.missouricb.com then click
on the Education Box/Online Home study link to view a list of preapproved providers of education. Review
of videos/films, literature or the like may not be included unless the videos/films or literature were part of the
training in a formal classroom setting.
Agency In-Service Hours:
An in-service training is any training provided only for the staff in your agency/company. If you are required
to provide copies of outside training certificates, this renewal period, you must provide an attendance
sheet showing you attended the training.
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 2
April 30, 2021 Renewal Instructions
PLEASE REFERENCE THE CHART BELOW IF YOU HAVE PREVIOUSLY RENEWED YOUR
CREDENTIAL: Please note: Due to COVID-19 the “Live” ethics requirement has been waived at this time-you
may now obtain your ethics hours in either in a “live”, webinar or online setting.
1. CCDP – 40 total hours; 6 ethics hours
2. CCDP-D 40 total hours; 6 ethics hours
3. CCJP –40 total hours; 6 ethics hours
4. RADC—40 total hours; 6 ethics hours
5. SQP, SQP-R, SQI, SQI-R – 40 total hours; 6 ethics hours
6. MAPS—40 total hours; 6 ethics hours
7. BIP – 36 total hours; 6 ethics hours
8. MRSS –20 total hours; 6 ethics hours
9. CPS –20 total hours; 6 ethics hours
10. CRPR –20 total hours; 6 ethics hours
11. CRPR-L—20 total hours; 6 ethics hours
12. CRPS – 40 total hours; 6 ethics hours
13. CGDC-14 total hours; 6 ethics, 8 gambling specific
14. MARS –6 total; 6 hours need to be medication specific hours
15. MPS—5 total hours; 3 hours ethics
16. CHW-C—20 total hours; 6 ethics hours
RENEWAL TIME LINE AND FEES:
Renewal materials postmarked on or before April 30, 2021
MARS ($30 if only renewing MARS and no other credential)— (If you are renewing any credential
along with your MARS; there is no charge for the MARS).
• One MCB Credential (including the CCJP, CCDP or the CCDP-D, RADC) - $190.00
• Two MCB Credentials (Including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $215.00
• Three MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) -$240.00
• Four MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $265.00
• Five MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR, CRPR-
L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $290.00
• Six MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR, CRPR-
L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $315.00
Inactive MCB Credential (CCJP, CCDP, CCDP-D, RADC)
• One Inactive MCB Credential (including the CCJP, CCDP, CCDP-D, RADC). -$95.00
• Two Inactive MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $107.50
• Three Inactive MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS,
CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) -$120.00
• Four Inactive MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $132.50
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 3
April 30, 2021 Renewal Instructions
• Five Inactive MCB Credentials (including the CCDP, CCDP-D, RADC, MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C) - $145.00
• Six Inactive MCB Credentials (including the CCJP, CCDP, CCDP-D, RADC MRSS, CPS, CRPR,
CRPR-L, SQP, SQP-R, SQI, SQI-R, CGDC, CRPS, MAPS, MPS, BIP, CHW-C)- $157.50
CRPS/MAPS Renewals & Inactive Fees
• CRPS/MAPS Renewal Fee - $100.00
• CRPS/MAPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
CRPR, CRPR-L, CGDC, MPS, BIP, CHW-C) - $125
• CRPS/MAPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
CRPR, CRPR-L, CGDC, MPS, BIP, CHW-C) - $150
• CRPS/MAPS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
CRPR, CRPR-L, CGDC, MPS, BIP, CHW-C) - $175
• CRPS/MAPS plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
CRPR, CRPR-L, CGDC, MPS, BIP, CHW-C) - $200
• Inactive CRPS/MAPS ONLY - $50
• Inactive CRPS/MAPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS,
CGDC, CRPR, CRPR-L, CGDC, MPS, BIP, CHW-C) - $62.50
• Inactive CRPR/MAPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS,
CGDC, CRPR, CRPR-L, MPS, BIP, CHW-C) - $75
• Inactive CRPR/MAPS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS,
CGDC, CRPR, CRPR-L, MPS, BIP, CHW-C) - $87.50
• Inactive CRPR/MAPS plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS,
CGDC, CRPR, CRPR-L, MPS, BIP, CHW-C) - $100
BIP Renewals & Inactive Fees
• BIP Renewal Fee - $70.00
• BIP plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-L,
CGDC, MPS, CHW-C- $95
• BIP plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-L,
CGDC, MPS, CHW-C- $120
• BIP plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-L,
CGDC, CHW-C - $145
• BIP plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-L,
CGDC, CHW-C - $170
• Inactive BIP ONLY - $35.00
• Inactive BIP plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS, CHW-C - $47.50
• Inactive BIP plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS, CHW-C - $60.00
• Inactive BIP plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR,
CRPR-L, CGDC, MPS, CHW-C - $72.50
• Inactive BIP plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS, CHW-C - $85.00
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 4
April 30, 2021 Renewal Instructions
CRPR & CRPR-L Renewals & Inactive Fees
• CRPR/CRPR-L Renewal Fee - $70.00
• CRPR/CRPR-L plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
MPS, CHW-C - $95
• CRPR/CRPR-L plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS, CGDC,
MPS, CHW-C - $120
• CRPR/CRPR-L plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS, CPS,
CGDC, MPS, CHW-C - $145
• Inactive CRPR/CRPR-L ONLY - $35
• Inactive CRPR/CRPR-L plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS,
CPS, CGDC, MPS, CHW-C - $47.50
• Inactive CRPR/CRPR-L plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS,
CPS, CGDC, MPS, CHW-C - $60
• Inactive CRPR/CRPR-L plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS,
CPS, CGDC, MPS, CHW-C - $72.50
• Inactive CRPR/CRPR-L plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R), MRSS,
CPS, CGDC, MPS, CHW-C - $85
MRSS Renewals & Inactive Fees
• MRSS Renewal Fee - $70.00
• MRSS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CPS, CHW-C -
$95.00
• MRSS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CPS, CHW-C -
$120.00
• MRSS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CPS, CHW-C
- $145.00
• Inactive Status for MRSS ONLY- $35.00
• Inactive MRSS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CPS,
CHW-C - $47.50
• Inactive MRSS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CPS,
CHW-C - $60
CPS Renewals & Inactive Fees
• CPS Renewal Fee - $70.00
• CPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CHW-C -
$95.00
• CPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CHW-C -
$120.00
• CPS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CHW-C -
$145.00
• Inactive Status for CPS ONLY- $35.00
• Inactive CPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CHW-C
- $47.50
• Inactive CPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS, CHW-C
- $60
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 5
April 30, 2021 Renewal Instructions
CHW-C Renewals & Inactive Fees
• CHW-C Renewal Fee - $70.00
• CHW-C plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS - $95.00
• CHW-C plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS - $120.00
• CHW-C plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS - $145.00
• Inactive Status for CHW-C ONLY- $35.00
• Inactive CHW-C plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS - $47.50
• Inactive CHW-C plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R), CGDC, MPS - $60
SATOP (SQP, SQP-R, SQI, SQI-R, SR) Renewals & Inactive Fees
• SATOP (SQP, SQP-R, SQI, SQI-R) Renewal Fee - $50.00
• SATOP (SQP, SQP-R, SQI, SQI-R) plus one of the following CGDC or MPS - $75
• SATOP (SQP, SQP-R, SQI, SQI-R) plus two of the following CGDC and MPS - $100
• Inactive Status for SATOP (SQP, SQP-R, SQI, SQI-R) - $25
• Inactive SATOP (SQP, SQP-R, SQI, SQI-R) plus one of the following CGDC or MPS - $37.50
• SATOP (SQP, SQP-R, SQI, SQI-R) plus two of the following CGDC and MPS - $50
CGDC Renewals & Inactive Fees
• CGDC ONLY Renewal Fee - $50.00
• CGDC Renewal Fee plus MPS - $75.00
• Inactive Status for CGDC - $25
• Inactive Status for CGDC plus MPS - $37.50
MPS Renewals & Inactive Fees
• MPS ONLY Renewal Fee - $25.00
• Inactive Status for MPS-$12.50
Renewal materials postmarked from May 1 to May 31, 2021 will be charged a late fee.
• CCDP, CCDP-D, CCJP, RADC Late Fee is an additional $75.00
• CRPS/MAPS Late Fee is an additional $75.00
• MPS Late Fee is an additional $20.00
• CRPR & CRPR-L Late Fee is an additional $40.00
• MRSS/CPS Late Fee is an additional $40.00
• CHW-C Late Fee is an additional $40.00
• SQP, SQP-R, SQI, SQI-R and SR Late Fee is an additional $20.00
• CGDC Late Fee is an additional $20.00
• MARS Late Fee is an additional $20.00
Renewal materials postmarked after May 31, 2021 will not be accepted and your credential will be
considered expired. In cases of disputes on when the renewal materials were mailed, the MCB will accept
only U.S. Postal Service marks as outlined in the MCB Policies and Procedures or email date stamps if you
submitted online.
Please Do Not Staple Check To Renewal Forms. Make checks payable to MCB
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 6
April 30, 2021 Renewal Instructions
The MCB accepts Visa, MasterCard and Discover Card.
Do Not Fax or Email Completed Renewal Forms to the MCB—THEY WILL NOT BE ACCEPTED!
UNABLE TO RENEW AT THIS TIME - MCB STAFF ASSISTANCE - If you have had a serious illness,
or an extended period of unemployment, or other serious event recently in your life and feel you cannot renew
your credential at this time, immediately call the MCB office (573) 616-2300. MCB Staff will make every
reasonable effort to work with you to help you successfully complete the renewal process so your MCB
credential(s) will not expire.
INACTIVE STATUS PROCEDURE:
1. Only Professionals who do NOT use their credential for employment purposes may request at the time of
their renewal to place their credential on inactive status.
2. At the time of their renewal when they request inactive status, the professional will only pay half of the
current renewal fee, complete the demographic information on the renewal form and sign the Code of
Ethical Practice and Professional Conduct and authorization and release.
3. At each renewal date to follow that the professional wishes to remain on inactive status – they pay half
of the current renewal fee and submit half the education hours required for that renewal period; complete
the renewal forms and sign the Code of Ethical Practice and Professional Conduct and Authorization
and Release.
4. To return to active status at the professional’s renewal date, he/she will pay the full renewal fee and
submit the total number of education hours as required; complete the renewal forms and sign the Code
of Ethical Practice and Professional Conduct and Authorization and Release.
5. Should a professional wish to return to active status at any point before their next renewal date
they will pay the full renewal fee and submit the total number of continuing education hours
required for their April 30, 2021 renewal. Their renewal date will remain the same.
REQUIREMENTS FOR RETIRED EMERITUS STATUS:
1. The Board may grant the classification, Retired Emeritus Status (RES) to credentialed professionals who are
fifty-five (55) years old, provided a minimum of ten (10) years of meritorious service and are retired from
employment.
2. Credentialed professionals who desire the emeritus status must send a letter of request to the Board office
indicating this request and the effective date of retirement. The Board staff will review all requests for the
emeritus status and if the applicant meets the requirements, the staff will approve the request and send a
notice to the applicant. If an applicant does not meet the criteria, they will be notified in writing by Board
staff.
3. No renewal fees will be paid for the retired emeritus status.
4. The retired emeritus status individual may identify himself or herself as a Professional Emeritus, and shall
continue to receive Board communication.
5. The retired emeritus status individual will be ineligible for IC&RC reciprocity and agrees to remain retired
with no intention of returning to employment.
6. With the Retired Emeritus Status designation, your MCB credential will expire.
7. If a retired emeritus status individual desires to reinstate their MCB credential, the individual must write a
letter of request to the board. They will need 15 hours of continuing education completed in the past six
months and they will be charged $50.00 to reinstate their credential.
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS, CRPR, CRPR-L,
MRSS, CHW-C and CPS Page 7
April 30, 2021 Renewal Instructions
MCB CREDENTIAL REINSTATEMENT POLICY
If you do not renew during this renewal period and your credential expires, you may request that your
credential(s) be reinstated and submit the renewal forms with education hours, pay the renewal fee(s) (not late
fees) and also pay an additional reinstatement fee before April 30, 2022. Your next renewal date will not
change. Education hours for your renewal must be obtained after your reinstatement date.
Contact MCB Staff at (573) 616-2300, or email: help@missouricb.com if you have additional questions.
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS,
CRPR, CRPR-L, MRSS, CHW-C and CPS Page
8
April 30, 2021 Renewal Instructions
DEMOGRAPHIC AND FEE PAGE
MISSOURI CREDENTIALING BOARD-428 EAST CAPITOL 2
ND
Floor; Jefferson City, MO 65101
Your Required Demographic Information Below (Please Type or Print Very Legibly)
____________________________________________________________________________________
(Name) First Middle Last
____________________________________________________________________________________
Current Home Address (Street/Apt/City/State/Zip)
Phone Number: _____________________ Work Phone Number: __________________
Place of Employment: _____________________________________
Email Address: ______________________________________
Your email address listed above will be used by MCB staff to correspond with you if there is a
problem with your renewal materials when they are reviewed. Check your SPAM folder for email
from MCB Staff.
Within the last renewal period have you been charged, found guilty, or entered a pleas of nolo
contendere, in a criminal prosecution under the laws of any state or the United States for any
offense, whether or not sentence was imposed or executed?
If yes, please attach a written explanation. ____ Yes ___ No
List Other Professional Counseling Credentials You Hold ___________________________________
Renewal Fee Payment Method: Check One
___ Check ___ Money Order ___ Agency Paying _______________________
___ Visa ___ Master Card ___ Discover Card
Card Number: _______________________________ 3 Digit Verification Code _________
Credit Card Expiration Date (mm/yy) _______________
Credit Card Authorization Signature: ________________________________
Please mark all credentials and write the credential numbers you are renewing at this time:
___ BIP ___ CCDP ___ CCDP-D ___ CCJP ___ CGDC ___ CPS
___ CRPR ___ CRPS ___ MAPS ___ MARS ___ MPS ___ MRSS
___ RADC ___ SQI ___ SQI-R ___ SQP ___ SQP-R ___ CHW-C
___ CRPR-L
click to sign
signature
click to edit
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS,
CRPR, CRPR-L, MRSS, CHW-C and CPS Page
9
April 30, 2021 Renewal Instructions
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
(573) 616-2303 (FAX) email: help@missouricb.com Jefferson City, MO 65101
Renewal Application—Attestation Statement
I, ______________________, attest I have completed all the necessary hours to renew my MCB
credentials for the April 30,
2021 Renewal including all required Ethics hours.
I understand that Missouri Credentialing Board (MCB) has the authority to request my
certificates/documentation
at any time and it is my responsibility to maintain my training certificates.
Signed By: _________________________
Date: _________________________
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS,
CRPR, CRPR-L, MRSS, CHW-C and CPS Page
10
April 30, 2021 Renewal Instructions
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
(573) 616-2303 (FAX) email: help@missouricb.com Jefferson City, MO 65101
Signature Page for Code of Conduct and Authorization and Release
I have read and will abide by the current MCB Treatment Ethics Code and/or the current MCB MRSS, CPS CRPR, CRPR-L BIP, CHW-C or
Prevention Ethics Code listed on the website (www.missouricb.com) under the MCB Ethics Code Link.
Authorization and Release
I hereby certify all of the information given herein is true and complete to the best of my knowledge and belief. I also authorize any relevant
investigations, or the release of personal information to the Missouri Credentialing Board, its agents, or contractors pursuant to this
application/renewal procedure. I understand falsification of any portion of this application/renewal will result in my being denied credentialing, or
revocation of same upon discovery.
I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff, peer evaluators and examiners, free from
any civil liability for damages or complaints by reason of any action that is within the scope and arise out of the performance of their duties which
they, or any of them, may take in connection with this application/renewal, the examination, the grades with respect to any examination, and/or the
failure of the MCB to issue me said credential or renewal.
This Authorization and Release shall also apply to personal information requested by the Board at any time following credentialing with
connection with any investigation concerning allegations that could lead to disciplinary action against me.
____________ _________________________________
Date Printed Name
____________ _________________________________
Date Signature
CCJP, CCDP, CCDP-D, CGDC, RADC, SQP, SQP-R, SQI, SQI-R, BIP, MARS, CRPS, MAPS, MPS,
CRPR, CRPR-L, MRSS, CHW-C and CPS Page
11
April 30, 2021 Renewal Instructions
Please remember to check to see if you were
audited in April 2021
And
EVERYONE
must send in a copy of their
Ethics Certificate:
All renewals MUST submit a copy of
their Ethics Training; however only
send in all training certificates if your
name was part of the April 2021
Renewal Audit. You can check the
MCB website to see if your name was
randomly selected for the audit.
www.missouricb.com
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Missouri Credentialing Board APRIL 30, 2021 RENEWAL FORMS (Missouri Credentialing Board)

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Completed 8 February 2021

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