Fillable Missouri Credentialing Board TABLE OF CONTENTS FOR OCTOBER (Missouri Credentialing Board)

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Missouri Credentialing Board TABLE OF CONTENTS FOR OCTOBER (Missouri Credentialing Board)

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CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
Missouri
Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
email: help@missouricb.com Jefferson City, MO 65101
TABLE OF CONTENTS FOR OCTOBER 31, 2020 RENEWAL FORMS FOR
Certified Alcohol Drug Counselor (CADC), Certified Reciprocal Alcohol Drug Counselor (CRADC), Certified
Reciprocal Advanced Alcohol Drug Counselor (CRAADC), Certified Criminal Justice Addictions Professional (CCJP),
Certified Co-Occurring Disorders Professional (CCDP), Certified Co-Occurring Disorders Professional-Diplomate
(CCDP-D), Certified Gambling Disorders Counselor (CGDC) Missouri Associate Alcohol Drug Counselor II (MAADC
II), SATOP Qualified Professional (SQP), SATOP Qualified Professional–REACT (SQP-R), SATOP Qualified
Instructor (SQI), SATOP Qualified Instructor-REACT (SQI-R) Medication Awareness Recovery Specialist Certificate
(MARS), Missouri Recovery Support Specialist (MRSS), Certified Peer Specialist (CPS), Certified Reciprocal Peer
Recovery (CRPR), Certified Reciprocal Peer Recovery-L (CRPR-L) Certified Reciprocal Prevention Specialist (CRPS)
Batterer Intervention Professional (BIP) and the Missouri Prevention Specialist (MPS).
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 ARE 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 October 2020 Renewal Audit. You can check the MCB website to see if your name
was randomly selected for the audit.
PLEASE REFERENCE THE CHART BELOW IF YOU HAVE PREVIOUSLY RENEWED YOUR
CREDENTIAL:
A. CADC – 40 total hours; 6 ethics hours
B. CRADC – 40 total hours; 6 ethics hours
C. CRAADC – 40 total hours; 6 ethics hours
D. CCJP –40 total hours; 6 ethics hours
E. MRSS –20 total hours; 6 ethics hours
F. CPS –20 total hours; 6 ethics hours
G. CRPR –20 total hours; 6 ethics hours
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
H. CRPR-L – 20 total hours; 6 hours ethics
I. CCDP – 40 total hours; 6 ethics hours
J. CCDP-D 40 total hours; 6 ethics hours
K. SQP, SQP-R, SQI, SQI-R – 40 total hours; 6 ethics hours
L. CGDC –14 total hours; 6 ethics hours
M. CRPS – 40 total hours; 6 ethics hours
N. MARS –6 total MARS hours
O. BIP – 36 total hours; 6 ethics hours
P. MAADC II—20 hours; 3 ethics hours
Q. MPS—5 hours; 3 ethics hours
RENEWAL OF YOUR MEDICATION AWARENESS RECOVERY SPECIALIST CERTIFICATE
(MARS):
If you hold the Medication Awareness Recovery Specialist, (MARS) certificate and need to renew it by
October 31, 2020. Your renewal hours from MARS must come from pharmacology and/or medication
awareness recovery education obtained after you obtained your MARS certificate or after October 31, 2018 if
you have renewed it before. There is not a renewal fee to renew your MARS certificate if you are also
renewing another MCB credential. If you are only renewing a MARS Certificate, the fee is $30.00. The 6
contact hours required to renew your MARS certificate may also be used as part of the education requirement to
renew your other MCB credentials at this time.
RENEWING YOUR MISSOURI RECOVERY SUPPORT SPECIALIST, CERTIFIED PEER
SPECIALIST, CERTIFIED RECIPROCAL PEER RECOVERY (CRPR) or CERTIFIED
RECIPROCAL PEER RECOVERY—Legacy (CRPR-L)
If you have renewed before, all renewal hours must be since October 31, 2018. You must submit 20 contact
hours of education that relates to the field of behavioral health. Outside education hours may be obtained from
workshops, seminars, and online or home study courses from a MCB online or home study provider (see MCB
web site under the education box) Please note: 6 of the 20 contact hours must be Ethics.
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 MCB pre-approved home study or online courses.
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, the in-service form MUST be signed
by your supervisor OR you must attach copies of the sign-in sheets for each in-service training listed.
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
RENEWAL TIME LINE AND FEES:
Renewal materials postmarked on or before October 31, 2020
• 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 CADC, CRADC, CRAADC, CCJP, CCDP or the CCDP-D) -
$190.00
• Two MCB Credentials (Including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, MRSS,
CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) - $215.00
• Three MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D,
MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) -
$240.00
• Four MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, MRSS,
CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) - $265.00
• Five MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, MRSS,
CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) - $290.00
• Six MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, MRSS,
CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) - $315.00
Inactive MCB Credential
• One Inactive MCB Credential (including the CADC, CRADC, CRAADC, CCJP, CCDP or the
CCDP-D). -$95.00
• Two Inactive MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D,
MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) -
$107.50
• Three Inactive MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-
D, MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) -
$120.00
• Four Inactive MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D,
MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) -
$132.50
• Five Inactive MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D,
MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS) -
$145.00
• Six Inactive MCB Credentials (including the CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D,
MRSS, CPS, CRPR, CRPR-L, SQP, SQP-R, SQI, SQI-R, SR, CGDC, CRPS, BIP or MPS)- $157.50
CRPS Renewal & Inactive Fees
• CRPS Renewal Fee - $100.00
• CRPS plus one of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS- $125.00
• CRPS plus two of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS $150.00
• CRPS plus three of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS - $175.00
• CRPS plus four of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS - $200.00
• CRPS plus five of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS - $225.00
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
• CRPS plus six of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP, MRSS,
CPS, CRPR, CRPR-L, CGDC, MPS - $250.00
• Inactive CRPS Renewal Fee - $50.00
• Inactive CRPS plus one of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP,
MRSS, CPS, CRPR, CRPR-L, CGDC, MPS- $62.50
• Inactive CRPS plus two of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP,
MRSS, CPS, CRPR, CRPR-L, CGDC, MPS $75.00
• Inactive CRPS plus three of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR),
BIP, MRSS, CPS, CRPR, CRPR-L, CGDC, MPS- $87.50
• Inactive CRPS plus four of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP,
MRSS, CPS, CRPR, CRPR-L, CGDC, MPS - $100.00
• Inactive CRPS plus five of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP,
MRSS, CPS, CRPR, CRPR-L, CGDC, MPS - $112.50
• Inactive CRPS plus six of the following MAADC II, SATOP (SQP, SQP-R, SQI, SQI-R, SR), BIP,
MRSS, CPS, CRPR, CRPR-L, CGDC, MPS - $125.00
MAADC II Renewals & Inactive Fees
• MAADC II -$95.00 (if only renewing MAADC II and no other credential)
• MAADC II plus one of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $120.00
• MAADC II plus two of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $145.00
• MAADC II plus three of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $170.00
• MAADC II plus four of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $195.00
• MAADC II plus five of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $220.00
• MAADC II plus six of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR) BIP,
CPS, MRSS, CPS, CGDC, MPS – $245.00
Inactive Fees
• MAADC II -$47.50 (if only renewing MAADC II and no other credential)
• MAADC II plus one of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS– $60.00
• MAADC II plus two of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $72.50
• MAADC II plus three of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $85.00
• MAADC II plus four of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS– $97.50
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
• MAADC II plus five of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR)
BIP, CPS, MRSS, CPS, CGDC, MPS – $110.00
• MAADC II plus six of the following CRPR, CRPR-L, SATOP (SQP, SQP-R, SQI, SQI-R, SR) BIP,
CPS, MRSS, CPS, CGDC, MPS – $122.50
BIP Renewals & Inactive Fees
• BIP Renewal Fee - $70.00
• BIP plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS- $95
• BIP plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS $120
• BIP plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR,
CRPR-L, CGDC, MPS - $145
• BIP plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR, CRPR-
L, CGDC, MPS - $170
• Inactive BIP ONLY - $35.00
• Inactive BIP plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR,
CRPR-L, CGDC, MPS - $47.50
• Inactive BIP plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS, CRPR,
CRPR-L, CGDC, MPS - $60.00
• Inactive BIP plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS,
CRPR, CRPR-L, CGDC, MPS - $72.50
• Inactive BIP plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR) MRSS, CPS,
CRPR, CRPR-L, CGDC, MPS - $85.00
CRPR & CRPR-L, Renewals & Inactive Fees—If you are renewing a CRPR or CRPR-L, there is no
additional fee for renewing the CPS or the MRSS
• CRPR or CRPR-L Renewal Fee - $70.00
• CRPR or CRPR-L plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS
- $95
• CRPR or CRPR-L plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS
- $120
• CRPR or CRPR-L plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS
- $145
• Inactive CRPR or CRPR-L ONLY - $35
• Inactive CRPR or CRPR-L plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR),
CGDC, MPS - $47.50
• Inactive CRPR or CRPR-L plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR),
CGDC, MPS - $60
• Inactive CRPR or CRPR-L plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR),
CGDC, MPS - $72.50
• Inactive CRPR or CRPR-L plus four of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR),
CGDC, MPS - $85
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
MRSS Renewals & Inactive Fees
• MRSS Renewal Fee - $70.00
• MRSS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $95.00
• MRSS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $120.00
• MRSS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $145.00
• Inactive Status for MRSS ONLY- $35.00
• Inactive MRSS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS -
$47.50
• Inactive MRSS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS -
$60
CPS Renewals & Inactive Fees
• CPS Renewal Fee - $70.00
• CPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $95.00
• CPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $120.00
• CPS plus three of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $145.00
• Inactive Status for CPS ONLY- $35.00
• Inactive CPS plus one of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS -
$47.50
• Inactive CPS plus two of the following SATOP (SQP, SQP-R, SQI, SQI-R, SR), CGDC, MPS - $60
SATOP (SQP, SQP-R, SQI, SQI-R, SR) Renewals & Inactive Fees
• SATOP (SQP, SQP-R, SQI, SQI-R, SR) Renewal Fee - $50.00
• SATOP (SQP, SQP-R, SQI, SQI-R, SR) plus one of the following CGDC or MPS - $75
• SATOP (SQP, SQP-R, SQI, SQI-R, SR) plus two of the following CGDC or MPS - $100
• Inactive Status for SATOP (SQP, SQP-R, SQI, SQI-R, SR) - $25
• Inactive SATOP (SQP, SQP-R, SQI, SQI-R, SR) plus one of the following CGDC or MPS - $37.50
• Inactive SATOP (SQP, SQP-R, SQI, SQI-R, SR) plus two of the following CGDC or MPS - $50.00
CGDC Renewals & Inactive Fees
• CGDC ONLY Renewal Fee - $50.00
CGDC plus the following MPS - $75.00
• Inactive Status for CGDC - $25
• Inactive CGDC plus the following MPS - $37.50
MPS Renewal & Inactive Fees
• MPS ONLY Renewal Fee - $25.00
• Inactive Status for MPS - $12.50
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
Renewal materials postmarked from November 1
st
to November 30, 2020 will be charged a late fee.
• CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D Late Fee is an additional $75.00
• MAADC II Late fee is an additional $75.00
• CRPS Late fee is an additional $75.00
• CRPR or CRPR-L Late Fee is an additional $40.00
• MRSS/CPS Late Fee is an additional $40.00
• BIP 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
• MPS Late Fee is an additional $20.00
Renewal materials postmarked after November 30, 2020 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. (If you want to reactive your credentials, you will have to complete the
reinstatement process).
Please Do Not Staple Check To Renewal Forms. Make checks payable to MCB
The MCB accepts
Visa, MasterCard and Discover Card.
Do Not Fax 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
October 31, 2020 renewal. Their renewal date will remain the same.
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
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.
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 October 31, 2021. 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.
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
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.
With in 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 Untied 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:
__ CADC __ CRADC __ CRAADC __ CCDP __ CCDP-D __ CCJP ___ CRPS
__ MAADC II __ CGDC __ MARS __ SQP __ SQP-R __ SQI ___ MPS
__ SQI-R __ MRSS __ CPS __ BIP __ CRPR __ CRPR-L
For Payment Amounts—Please see renewal instructions on MCB Website (www.missouricb.com)
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
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 October 31,
2020 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.
I understand that if my renewal is being audited, I must submit a copy of all my training certificates for review. I
further understand that even if I am not being audited, I still must submit a copy of my ethics certificate in order
to renew my credentials.
Signed By: _____________________
Date: _________________________
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
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, BIP
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
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
This page is for MAADC II renewals only
Missouri Credentialing Board
428 East Capitol-2
nd
Floor, Jefferson City, MO 65101
(573) 616-2300
MENTORING AND CLINICAL SUPERVISION AGREEMENT AND
PROFESSIONAL DEVELOPMENT CONTRACT
Mentoring and Clinical Supervison Agreement
Adapted from Stiehl, R. and Bessey, B. (1994)
THIS FORM MUST BE SIGNED BY A MCB QUALIFIED SUPERVISOR
MCB Qualified Supervisor includes an individual who holds a CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC,
RADC-P, SQP/SQP-r, LPC, LCSW, LMFT or Licensed Psychologist and has completed the MCB Clinical
Supervision Training. This cannot be an immediate family member. (This form covers both the Mentoring and
Clinical Supervision Agreement and Professional Development Contract).
Step 1: Agree to work together
• Agree on working together toward improving the supervisee’s counseling skills
Step 2: Define and agree on learning goals
• The learning goals must be clearly defined, and there needs to be agreement to work together to help the
supervisee attain proficiency in the skills chosen
Step 3: Understand the value of the goals
• The supervisee needs to understand the value of achieving the agreed upon goals
Step 4: Break goals into manageable parts
• The overall goals need to be broken down into parts such as: a) the knowledge, b) the skills, c) the attitudes
necessary to attain proficiency
Step 5: Pick styles and methods of learning
• The supervisor needs to elicit from and negotiate with the supervisee his or her preferred styles and methods
of learning
Step 6: Observe and evaluate
• How progress will be observed and evaluated needs to be discussed and agreed upon
Step 7: Provide feedback
• The supervisor needs to know how to give feedback which guides, corrects, and at the same time encourages
Step 8: Demonstrate competency and celebrate
• An outcome demonstration of the newly acquired skill which confirms success needs to be designed,
followed by a celebration of the accomplishment
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
This page is for MAADC II renewals only
Professional Development Contract
Purpose, Goals and Objectives of Supervision:
• Monitor and promote welfare of clients seen by Supervisee
• Promote development of Supervisee’s professional identity and competence by using the tools learned in the
Clinical Supervision: Building Chemical Dependency Counselor Skills Training
• Oversee Supervisee’s entrance and advancement in the credentialing process
• Ensure ethical standards are maintained
Supervision Methods:
• Face to face sessions
• Supervisee attending trainings (both in-service/outside)
• File and documentation review
• Use of forms learned during clinical supervision training (Rubrics, Competency Rating Form, PDP, etc…)
• Preparing the case presentation when applying for certification
Evaluation of Supervisee:
• Feedback will be provided during each face to face session
• A formal evaluation will be conducted every 90 days using the Competency Rating Forms and Professional
Development Plan to identify improvement areas
Supervisee Responsibilities:
• Maintain ethical guidelines and professional standards
• Improve personal knowledge, skills and attitude by following the Professional Development Plan and advice of
supervisor
• Attend trainings to stay current in the field
• Perform all duties while keeping the client’s best interest in mind
We agree, to the best of our ability to uphold the guidelines specified in the supervision contract and to manage the
supervisory relationship process according to the ethical principles and code of conduct of the MCB. Signing this
form covers both the Mentoring and Clinical Supervision Agreement and the Professional Development Contract.
MAADC II Printed Name: ___________________________________ Date: ______________
MAADC II Signature: ________________________________________ Date: ______________
Supervisor Printed Name: ____________________________________ Date: ______________
Supervisor Signature: ________________________________________ Date: ______________
Clinical Supervision Training Certificate Number (not credential number): _____________
CADC, CRADC, CRAADC, CCJP, CCDP, CCDP-D, CGDC, MAADC II, SQP, SQP-R, SQI, SQI-R, MARS, MRSS, CPS, CRPR, CRPR-L, CRPS,
MPS and the BIP October 31, 2020 Renewal. DO NOT FAX TO THE MCB
Reminder:
All Renewals MUST submit a copy
of their ethics certificate.
Please check the website at
www.missouricb.com to see if you
are part of the October 2020 Audit.
If you are audited, you must submit a
copy of all of your required
educational certificates for review.
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Missouri Credentialing Board TABLE OF CONTENTS FOR OCTOBER (Missouri Credentialing Board)

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Completed 28 August 2020

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