Fillable Missouri Credentialing Board I. Criteria Criteria for Certified (Missouri Credentialing Board)

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Missouri Credentialing Board I. Criteria Criteria for Certified (Missouri Credentialing Board)

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Revised November 2020 CRPR Application Page 1
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
e-mail: help@missouricb.com Jefferson City, MO 65101
Criteria for Certified Reciprocal Peer Recovery (CRPR)
I. Criteria
Minimum of HS Diploma/HSE
2,000 hours of applicable work/volunteer experience within the last 10 years
Professional Reference Form from one of the following professionals: QMHP, QAP, Director of a
Certified Recovery Support Program or Director of a Consumer Operated Service Program.
100 hours of training/education as follows:
• CPS Training
• 10 hours in Advocacy (Covered by CPS training)
• 10 hours in Mentoring/Education (Covered by CPS training)
• 10 hours in Recovery/Wellness Support (Covered by CPS training)
• 16 hours in Ethical Responsibility (3 hours Covered by CPS training)
• 8 Hours of Mental Health or Youth Mental Health First Aid training
• 44 Additional Hours that relate to behavioral health/peer support
• 20 of the 100 hours must be obtained within the previous 12 months of applying
25 hours of peer supervision in the IC&RC peer recovery domains
Must currently hold the MCB Certified Peer Specialist credential
Pass the IC&RC International Peer Recovery Examination
APPLICABLE WORK/VOLUNTEER EXPERIENCE
Work/Volunteer experience is defined as experience in the Peer Recovery domains. Experience as a volunteer,
intern, or unpaid practicum qualifies as work experience if the experience is the same that a paid employee
would perform.
All qualifying experience must have been accrued during the ten (10) years immediately prior to application
being made.
All experience must be verified by a Work/Volunteer Verification form from the organization(s) in which the
applicant has experience.
SUPERVISED PRACTICUM IN THE PERFORMANCE DOMAINS is defined as receiving supervision
related to the peer performance domains.
The supervision of the experience of providing the performance domains may take place within an academic
setting and/or within a supervised work setting. The goal is to receive supervised experience in all of the
performance domains.
Revised November 2020 CRPR Application Page 2
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
CHECK LIST FOR CRPR APPLICATION
1. You have submitted a $200.00 check with this application or have provided your credit/debit card
information on page 5 of this application packet. Applications will not be reviewed until payment is
received.
2. You have completely filled out the application.
3. You have signed the CRPR Code of Ethics.
4. You have filled out the Family Care Safety Registry Worker Registration Form and included the form
with your packet. If your agency has conducted a FCSR background check on you within the last 30 days,
you may submit the results to help expedite the application process.
5. The appropriate person has completed and signed the Work/Volunteer Verification Form and you have
included the completed form with the application.
6. The Supervised Practicum form has been completed by an appropriate professional and been included
with the application.
7. The appropriate certificates were included to verify the required educational/training hours.
8. The appropriate High School/HSE or College transcripts were included.
9. The Reference Form has been filled out by a Qualified Professional Reference and been included with the
application.
10. Typically, applications are reviewed within two weeks of receipt in the MCB office. If you have not
received written correspondence from the MCB 3 weeks after mailing your application, call the MCB.
11. Check the Professional Search on the MCB website homepage at www.missouricb.com. Type in your last
name. If your application is complete, your credential information will be displayed and you should have
received your welcome letter and certificates by e-mail.
12. Refer to the Peer Recovery Candidate Guide on the MCB website www.missouricb.com under the
Education Box/Candidate Guide link for the Peer Recovery domain definitions.
Revised November 2020 CRPR Application Page 3
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
Application Instructions:
1. Requirements to receive this credential are subject to change without notice. Please make sure you are
submitting the most recent application packet. If you are unsure, contact the MCB office.
2. The application must be typed or neatly printed.
3. Please keep a copy of all materials submitted for your records.
4. FEES: The total CRPR Fee is $200.00. You may pay by check, money order, or provide credit card
information on page 5 of this application packet. Applications will not be reviewed until payment is
received.
5. Please be aware that should your application be reviewed and additional information is requested to
complete the application, you will have 90 days to provide the requested information. Failure to do so
will result in your application expiring without being approved.
6. All fees are non-refundable. If your application is denied or expires, fees will not be refunded.
7. If your application is denied, you may contact the MCB office staff for instructions on how to appeal the
denial of your application.
8. All materials submitted to the MCB office become property of the MCB.
9. The applicant must currently reside and/or work/volunteer in the State of Missouri at least 51% of the
time. The only exception to this is applicants living and working in a state that is not a member of the
International Certification and Reciprocity Consortium.
10. The CRPR credential has a 2 year renewal and for each renewal, a professional needs 20 total CEUs
with 6 of those being live ethics.
11. Please remember that it is your responsibility to keep the MCB office informed of any personal
informational changes such as address and phone number changes. If you fail to notify us of changes,
you will be responsible for any material that is mailed to the wrong address and will have to pay a fee to
have the material sent again.
12. Please mail your application to the MCB. Please do not fax or e-mail your application.
Revised November 2020 CRPR Application Page 4
Useful Information:
1. If at any time during the application process, a question arises regarding an applicant’s moral character,
reputation for honesty, integrity, or professionalism, the Board may deny the application at that time or
place the application on hold until an investigation has been done and a decision made regarding the
question brought up.
2. Once your application has been accepted and has final approval, you will receive a letter from our office
with further instructions on how to continue the application/testing process. With this letter, you will
also receive information on how to obtain a free Candidate Guide from our web site. This guide provides
you sample questions for the exam.
3. The CRPR credential is a reciprocal credential with other IC&RC member boards that offer the peer
recovery credential. You can contact the MCB office for more information on reciprocity.
Important Notice To Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to those
seeking a MCB credential.
1. No individual currently under any type of court supervision can apply for a MCB credential. Please
wait until you are completely free from court supervision before applying.
2. The following items disqualify an individual from ever being credentialed with the MCB:
A. Is listed on the Department of Mental Health disqualification registry
B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept. of
Social Services
C. Any crime against a minor
D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of
the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only disqualify
an applicant if the crime (s) were a felony. Please view information about Section 630.170, RSMo
on the MCB web site www.missouricb.com under the Disqualifying Crimes Link.
3. If an individual has applied for and been given an exception from the Department of Mental Health, the
individual may apply for a MCB credential. Please send in proof of exception with your application.
Revised November 2020 CRPR Application Page 5
APPLICATION
FOR
Certified Reciprocal Peer Recovery (CRPR)
Appropriate fee must be submitted with application.
MISSOURI CREDENTIALING BOARD
428 E. Capitol, 2
nd
Floor
JEFFERSON CITY, MISSOURI 65101
TELEPHONE: (573) 616-2300
WEB SITE: www.missouricb.com
EMAIL: help@missouricb.com
Please Mark Credit Card Type:
1. Visa _____________
2. MC _____________
3. Discover _____________
CC Expiration Date: _____/_______
Credit Card #: __________-______________-______________-____________
Credit Card 3 Digit Verification Code: ________________________________
Revised November 2020 CRPR Application Page 6
THIS APPLICATION MUST BE TYPED OR PRINTED NEATLY
All Applications Become the Property of MCB
Applicant’s Name: ___________________________________________________________________________
First Middle Last Name Suffix (Jr., II)
___________________________________________________________________________________________________________
Maiden Other Names Used
Current Home Address: _____________________________________________________________________________
Street/PO Box Apt. #
______________________________________________________________________________________________________________________
City State Zip County
Home Telephone: ________/_______________ SSN: __________-________-______________
Work Telephone:
________/_______________, Ext. ________ Cell Number: ________/_______________
E-mail Address:
_____________________________________________________________________________
SEX: ____M ____F BIRTH DATE: _____/_____/____________
Are you currently or have you been credentialed or licensed as a Substance Use Disorder Professional by the MCB or any
other state or organization? ______Yes ______No
If yes, which state/organization and when? _____________________________________________________________
What is the type of credential/license held with the other state/organization?
_________________________________________________________________________________________________
Have you ever been ARRESTED and/or CONVICTED of a felony? ____Yes ____No
If yes, please go to the www.missouricb.com website, print off the “Felony Offense Form”, fill out the form and submit
with your application. If you were convicted of a felony listed in Section 630.170 RSMo (view www.missouricb.com;
Disqualifying Crimes link), you may not apply for this credential without an exception from the Department of Mental
Health.
Have you ever knowingly been contacted by a Children’s Divsion employee regarding a CHILD ABUSE and/or CHILD
NEGLECT incident involving you? ______Yes ______No
If yes, please go to the www.missouricb.com website, print off the “Child Abuse/Neglect Statement”, fill out the form
and submit with your application. In addition, please contact the Children’s Division at 573-751-4920 and request a
report of the incident to include with this application.
Revised November 2020 CRPR Application Page 7
Education/Degree Information
Please mark your highest level of education completed:
1. High School Diploma/HSE: _____
2. Addiction Certificate Program: _____
3. Associate Degree: _____ Degree Program: ________________________
4. Bachelor Degree: _____ Degree Program: ________________________
5. Master Degree/Higher: _____ Degree Program: ________________________
An applicant may document High School Diploma or HSE or College/University degree by:
1. Submitting copy of High School Diploma/HSE
2. Submitting official or unofficial College/University transcripts. Please ensure the transcript shows the
applicable degree being conferred.
Where Does the Applicant Currently Work?
Name of Employer:
Mailing Address of Employer Street City State Zip Code County
Name & Title of Immediate Supervisor:
Your Business Phone: Area Code/Telephone Number Extension Fax # Area Code/Telephone Number
Training Requirements
All applicants must submit proof of the following live education requirements:
A. Complete CPS training program
B. 13 Additional live ethics hours
C. 8 hours of Mental Health First Aid training
D. 44 additional hours related to behavioral health/peer support
Please submit appropriate paperwork verifying the training hours listed above.
Revised November 2020 CRPR Application Page 8
Applicant’s Agreement to the Recovery Code of Ethical Practice and Professional
Conduct
I have read the Current Certified Peer Specialist Ethics Code as listed on the MCB web site
www.missouricb.com
, MCB Ethics Code Link and agree to abide by this code:
Print Name Date
Signature Date
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, any 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 in connection with any investigation concerning allegations that could lead to
disciplinary action against me.
Print Name Date
Signature Date
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Revised November 2020 CRPR Application Page 9
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
FAMILY CARE SAFETY REGISTRY
WORKER REGISTRATION
PLEASE TYPE OR PRINT CLEARLY
SECTION A: WORKER TYPE (CHECK ONE BOX ONLY)
CHILD CARE WORKER ($9.00) PERSONAL CARE WORKER ($9.00)
xx
VOLUNTARY
REGISTRANT
ELDER CARE WORKER ($9.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($9.00) FOSTER PARENT
(NO FEE)
SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING
LAST NAME
FIRST NAME
MIDDLE NAME
MAIDEN AND PRIOR NAMES USED
(ATTACH COPY OF SOCIAL
SECURITY CARD)
- -
DATE OF BIRTH
/ /
GENDER
MALE
FEMALE
TELEPHONE NO.
(OPTIONAL)
( )
MAILING ADDRESS
STREET ADDRESS OR POST OFFICE BOX
CITY
STATE
ZIP CODE
COUNTY
HOME ADDRESS (if different than mailing address)
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
SECTION C: CURRENT EMPLOYER INFORMATION (IF APPLICABLE)
EMPLOYER NAME
CONTACT PERSON
PHONE NUMBR
( )
ADDRESS
CITY
STATE
ZIP CODE
SECTION D: AUTHORIZATION TO RELEASE BACKGROUND SCREENING INFORMATION
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I
grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by law to process this
request. Futhermore, I authorized the Missouri Department of Health and Senior Services to release the fact that I am a registrant in the Family Care Safety Registry
(FCSR) and any related background information to the requestor of the FCSR for employment purposes only, as provided in 210.921, subsection 1 subdivision (1) and
(2), RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective employer/employee relationships, and
screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal care setting. I
understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy in the transfer of information to the FCSR within thirty (30)
days of receiving the results of the background screening determination.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to your designated bank account. I understand that my signature
below authorized my Financial Institution to deduct this payment from my account. In the event that DHSS or its subcontractor, is unable to secure funds from your
account or you provide insufficient or inaccurate information regarding your account, your obligation to the DHSS will remain unpaid and further collection action may
be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT (REQUIRED IN INK)
DATE
/ /
IMPORTANT
• Individuals are required to register one time only.
• Contact 1-866-422-6872 (toll-free) if you have questions on how to complete this form
• Read back of form for instructions and information on registrant notification and appeal rights
• Send completed registration form, copy of Social Security card and required fee to:
Missouri Department of Health and Senior Services
Attn: Fee Receipts
P.O. Box 570
Jefferson City, MO 65102
MO 580-2421 (FP)
Submit this form with your application and a copy of your SS card. If your
agency has ran a FCSR check within the last 30 days, you can submit the
results with this form which may speed up the application
process. By
doing so, you give permission for your agency to share their FCSR results.
Revised November 2020 CRPR Application Page 10
Missouri Credentialing Board
428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101
WORK/VOLUNTEER VERIFICATION FORM
An applicant is applying to the MCB for a Certified Reciprocal Peer Recovery Credential. Please complete this
form and provide a copy to the applicant to include with their application.
Applicant's Name: __________________________________________________________________________
Supervisor's Name (Print):______________________________________________________________________
Organization Name: __________________________________________________________________________
Address: ___________________________________________________________________________________
___________________________________________________________________________________________
Telephone: _________________________________________________________________________________
E-mail: _____________________________________________________________________________________
Today’s Date: _______________________________________________________________________________
Within the last 10 years from the date listed above, please list the composite total number of hours the
applicant spent working with behavioral health clients in the following domains: (Please list all hours worked
as this form replaces any previous employment forms submitted with prior applications)
The formula for computing hours is to take the total number of months worked within the last 10 years and
multiply that by 167 hours per month to get the total number of hours. Then divide that total number as
appropriate into the 4 domains below.
A
dvocacy: ______________________________________________________________________
Mentoring/Education: ______________________________________________________________________
Recovery/Wellness Support: ______________________________________________________________________
Ethical Responsibility: ______________________________________________________________________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
Revised November 2020 CRPR Application
11
Mi
ssouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
E-mail: help@missouricb.com Jefferson City, MO 65101
SUPERVISED PRACTICUM OF THE PERFORMANCE DOMAINS
INSTRUCTIONS: On this form, document only the number of hours the applicant has already completed in
each domain. A minimum of 25 total hours must be documented. Please complete this form and provide a copy
to the applicant to include with their application.
Applicant's Name(Print):___________________________________________________________
Supervisor (Print):__________________________________________________________________________________________
Agency:__________________________________________________________________________________________________
Total # Supervision Hours (Must be a minimum of 25 hours):__________________________________________________
Please indicate on the domain lines below how many of the Total # Supervision Hours listed above were in each domain. The total
listed on the line above should equal the sum total of the 4 domains:
A
dvocacy: ______________________________________________________________________
Mentoring/Education: ______________________________________________________________________
Recovery/Wellness Support: ______________________________________________________________________
Ethical Responsibility: ______________________________________________________________________
Supervisor's Name (Printed): ___________________________________________________________________
Supervisor’s Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
Revised November 2020 CRPR Application
12
Mi
ssouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
E-mail: help@missouricb.com Jefferson City, MO 65101
P
ROFESSIONAL REFERENCE FORM
The individual completing this form should be able to provide a professional reference for the applicant.
This form can only be filled out by a QMHP, QAP, a Director of a Certified Recovery Support Program
or a Director of a Consumer Operated Service Program. This form cannot be filled out by an immediate
family member. Please complete the form and give a copy to the applicant to include with their
application.
I. Name of Applicant: ________________________________________________________
II. Name of Reference (Print):__________________________________________________
III. Relationship to Applicant:___________________________________________________
IV. Credential or License Held If Applicable:_______________________________________
V. Reference Phone Number:__________________________________________________
VI. Reference Address:________________________________________________________
VII. Reference Signature___________________________________ Date:______________
Please describe the nature of your relationship with the applicant and describe why you believe the applicant is
qualified to be a Certified Reciprocal Peer Recovery:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever known the applicant to operate in an unethical manner while performing duties related to the
field of substance use disorders and if so, please describe the behavior?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Revised November 2020 CRPR Application
13
DOCUMENTATION OF DISABILITY-RELATED NEEDS
Please have this section completed by an appropriate professional (physician, psychologist, psychiatrist) to ensure that
your board is able to provide the required exam accommodations. Submitted documentation must follow ADA guidelines
in that psychological or psychiatric evaluations must have been conducted within the last three years. All
medical/physical conditions require documentation of the treating physician’s examination conducted within the previous
three months.
Professional Documentation:
I
have known ___________________________________________ since _____/_____/_____ in my
Exam Candidate Date
capacity as a ______________________________________________.
Professional Title
The candidate discussed with me the nature of the exam to be administered. It is my professional opinion that,
because of this candidate’s disability described below, he/she should be accommodated by providing the special
arrangements listed below:
D
escription of Disability:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signed: ______________________________________________________ Title: ___________________________
P
rinted Name: _________________________________________________________________________________
A
ddress: ______________________________________________________________________________________
C
ity/State/Zip: _________________________________________________________________________________
T
elephone Number: _____________________________ Email:__________________________________________
License Number: _______________________________ Date: ___________________________________________
(if applicable)
Revised November 2020 CRPR Application
14
REQUEST FOR SPECIAL ACCOMMODATIONS
If you have a disability that requires special testing accommodations, please complete this form and the Documentation of
Disability-Related Needs and return it to your IC&RC member board for processing. The information you provide and
any documentation regarding your disability and your need for accommodations in testing will be treated with strict
confidentiality. Submitted documentation must follow ADA guidelines in that psychological or psychiatric evaluations
must have been conducted within the last three years. All medical/physical conditions require documentation of the
treating physician’s examination conducted within the previous three months.
Preferred Exam Date: ________________ Preferred Exam Location: __________________________________________
Name: ____________________________________________________________________________________________
Home Address:_____________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________
Daytime Telephone Number: _________________________________________________________________________
Email: ____________________________________________________________________________________________
Special Accommodations:
I request special accommodations for the following IC&RC ADC examination
Please provide (check all that apply):
________ Special seating or other physical accommodations
________ Reader
________ Large print exam
________ Extended testing time (time and a half)
________ Distraction-free room
________ Other special accommodations (please specify)
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________________________________________________
Print Name: _______________________________________________________________________________________
Signature: _________________________________________________________________________________________
Date:_____________________________________________________________________________________________
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Missouri Credentialing Board I. Criteria Criteria for Certified (Missouri Credentialing Board)

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