Fillable PCB Peer CPS 2021 (Pennsylvania Certification Board)

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PCB Peer CPS 2021 (Pennsylvania Certification Board)

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PCB CPS 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. An application is considered approved when applicant receives an email from PCB to register for the
examination.
5. Follow all instructions to register for the examination provided in the email.
6. If you have not heard from PCB regarding your application or received an email from PCB to register for
the examination after 10 business days, email info@pacertboard.org
.
7. Once you pass the examination, you are certified.
8. A certificate will be mailed to you within 10 business days.
CPS APPLICATION
Certified Peer Specialist
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
2
CERTIFIED PEER SPECIALIST REQUIREMENTS
All requirements below must be met to apply. All required documentation must be sent in with an application.
PEER TRAINING
REQUIRED: 75 hours of mandatory peer specialist training.
Three training vendors are authorized to provide the 75-hour mandatory peer specialist
training. No other peer trainings are acceptable other than trainings from one of the three
authorized training vendors. All education/training must be documented.
The three authorized training vendors are:
Copeland Center: https://copelandcenter.com/our-services/certified-peer-specialist-training-cps
The Institute for Recovery: https://www.mentalhealthpartnerships.org/peer-specialist
RI Consulting: https://riinternational.com/consulting-and-training/
The required mandatory training is documented with a copy of the completed training certificate.
If you no longer have a copy of your 75-hour peer specialist training certificate, you must contact the training vendor
from whom you took your training for a replacement copy.
WORK/VOLUNTEER EXPERIENCE OR POST-SECONDARY EDUCATION
REQUIRED: One of these two is required:
1. Within the last three years, maintained at least 12 months of successful work or
volunteer experience; work or volunteer experience does not need to be specific to peer
support OR
2. Within the last three years, document 24 credit hours from a college/university.
If you choose the option of at least 12 months of successful work or volunteer experience within the last three
years, complete the work/volunteer experience page (page 8) of this application.
If you choose the option of at least 24 credit hours from a college/university within the last three years, you
must include a copy of your college transcript with this application.
Only one of these two options is required.
PERSONAL, LIVED EXPERIENCE
REQUIRED: The CPS credential is for persons with serious mental health or co-occurring
(mental health & substance use disorder) personal, lived experience.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
3
EXAMINATION
REQUIRED: Once application is approved, applicant must pass the PCB Examination for
Certified Peer Specialist (CPS examination).
CERTIFICATION FEE
REQUIRED: $150.00
(fee includes examination and 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 6 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.
Office of Vocational Rehabilitation (OVR) Payments: PCB is an approved vendor of OVR. If OVR is paying for your
application fee, it highly recommended payment processing is initiated at least three weeks prior to application
submission. CPS applications will not be approved until payment is received. Delay in payment can significantly
delay the application process.
One-half of the fee is refundable if application is denied or cancelled prior to the examination. No refund will be
issued if application is denied or cancelled after examination.
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 or register you for the examination without an email address. Please print legibly.
Applicants must either live or work in PA at the time of application.
This certification is a non-reciprocal credential recognized and used only in PA.
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.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
4
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.
EXAMINATION INFORMATION
TYPE OF EXAMINATION
The successful completion of the PCB CPS examination is required. There are two options for taking the
examination: an on-demand computer-based examination or a paper/pencil examination given regionally in
Pennsylvania on limited dates/locations. The examination consists of 50 multiple-choice questions. Once an
application is approved, candidates will receive an email from PCB with instructions for choosing the format to
take the examination.
TIME PERMITTED
One and one-half hours are permitted to complete the examination.
EXAMINATION CONTENT
The examination is developed from the SAMHSA Core Competencies for Peer Workers in Behavioral Health.
PCB has summarized the SAMHSA Core Competencies into the following categories for the examination:
1. Recovery planning and collaboration which includes recovery planning goals, etc., WRAP, documentation,
wellness tools, relapse prevention/signs, daily maintenance plans.
2. Ethical responsibility and professionalism which includes boundaries, ethics, confidentiality, self-care,
mandated reporting.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
5
3. Person-centered and relationship-focused which includes trauma-informed, communication,
storytelling/self-disclosure, self-advocacy, links to resources, stigma, active/reflective listening, definition of
peer support, resilience, stressors, hope.
CANDIDATE GUIDE
The domains, including the task statements per domain, sample examination questions, and a list of references
are included in the Candidate Guide. Candidate Guides are available from the PCB website.
SPECIAL SITUATIONS AND ACCOMMODATIONS
Individuals with disabilities and/or religious obligations that require modifications in examination administration
may request specific procedure changes in writing with official documentation to PCB no fewer than 60 days
prior to their examination date. Contact PCB on what constitutes official documentation. PCB will coordinate
appropriate modifications to the examination process when documentation supports the need.
CANCELLATION/RESCHEDULING POLICY
Candidates are required to arrive on time for their paper/pencil examination. Candidates who arrive late will not
be permitted to take the examination and will be charged a $75.00 cancellation/rescheduling fee. Candidates
who cancel or reschedule their examination less than five days prior to their scheduled date will be charged the
full examination fee. Candidates who cancel or reschedule more than five days before their scheduled date will
be charged a $25.00 cancellation/rescheduling fee.
RETESTING
Candidates who fail the examination can retest after a 30-day wait period from the date of their last
examination. Candidates will be sent instructions and fee information. Candidates have three (3) opportunities
to retake an examination. If a candidate fails the examination four (4) times, they must submit a study plan to
PCB and wait one-year from the date of the final failed examination before they will be permitted to retest
again.
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
6
CPS 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:
□ 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:
REQUIRED 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 $150 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 CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
7
CPS: PEER TRAINING
REQUIRED: 75-hour peer specialist training.
I have included a copy of my training certificate for the 75-hour peer specialist training with this application.
□ Yes
□ No
The training vendor who provided me with my 75-hour peer specialist training was:
□ Copeland Center
□ The Institute for Recovery
□ RI Consulting
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
8
CPS: WORK/VOLUNTEER EXPERIENCE OR POST-SECONDARY EDUCATION
REQUIRED: One of these two is required:
1. Maintained at least 12 months of successful work or volunteer experience within the last three
years; work or volunteer experience does not need to be specific to peer support OR
2. Document 24 credit hours from a college/university within the last three years.
CURRENT WORK/VOLUNTEER INFORMATION
Employer Name:
How many hours do you work/volunteer per week? ______________________________________________________
Are you currently employed/volunteering full-time or part-time? ___________________________________________
Total months of successful work/volunteer experience: ____________________________________________________
PREVIOUS WORK/VOLUNTEER INFORMATION
Employer Name:
How many hours do you work/volunteer per week? ______________________________________________________
Were you employed/volunteering full-time or part-time? __________________________________________________
Total months of successful work/volunteer experience: ____________________________________________________
OR
COLLEGE/POST-SECONDARY EDUCATION
I have received at least 24 credit hours of education from a college/university within the last three years. □ Yes □ No
I am documenting my college credits and have included a copy of my transcript in this application. □ Yes □ No
I am documenting my college credits and have ordered a transcript to be sent to PCB. □ Yes □ No
College/University: __________________________________________________________________
Name on Transcript: _________________________________________________________________
Date Transcript Requested: ___________________________________________________________
Delivery Method: □ Mailed to PCB □ Emailed to PCB
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
9
CPS: ATTESTATION OF LIVED EXPERIENCE
REQUIRED: Candidates for the CPS credential must have personal lived experience with a serious
mental health or co-occurring disorder.
I attest that I am a person with serious mental health or co-occurring lived experience.
__________________________________________ _____________________________
Applicant Signature Date
click to sign
signature
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PCB CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
10
CPS: 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 attest that I am at least 18 years of age or older.
I either live or work in Pennsylvania at least 51% of the time.
I understand one-half of the application fee is refundable if application is denied or cancelled prior to the
examination and no refund will be issued if application is denied or cancelled after examination.
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 prior to
the examination, or after an unsuccessful attempt at the examination 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 CPS Application | www.pacertboard.org | info@pacertboard.org | Revised January 2021
11
CPS: 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 6
Peer training page
• Page 7
Work/Volunteer Experience OR college credit
• Page 8
Attestation page
• Page 9
Notarized Acknowledgement & Release page
• Page 10
Checklist page
• Page 11
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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Completed 3 June 2021

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