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- NCCAP NCPRSS Application 03.2017

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Page 1 of 11
Credential APPLICATION FOR
N
ATIONAL CERTIFIED PEER RECOVERY SUPPORT SPECIALIST
Please note: If any documentation required for the NCPRSS credential application was issued under
a previous name, you must submit a copy of the legal document to verify the change. (If by divorce,
copy only that portion of the document showing the name change.)
I. Personal Data
Dr. Mr. Ms. Other:_______
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City/State/ZIP+4 __________________________________________________________________
Phone (w): _____________________ (cell): _____________________ (f): ___________________
E-mail: _________________________________________________________________________
II. Payment/Fee Information
Credential: NCPRSS Application Fee: $ 235.00 (non-refundable)
Amount Enclosed: $______.00 (check/money order payable to NCC AP)
Credit card amount: $______.00 Company card Personal card
MasterCard Visa American Express
_____________________________________________________________
Full name of card holder (please print)
__________________________________________________ _________
Credit card number Exp Date
_________________________________________ __________________
Signature Date
NCC AP NCPRSS Credential Application 01-2019
OFFICE USE ONLY
Date
Received:______________________
Check/MO #: __________________
Credit Card:
Visa MC Amer Exp
Amount Paid: $________________
Proc
essed Date:________________
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NCC AP NCPRSS Credential Application 01-2019 Page 2 of 11
III. NCPRSS Credential Eligibility & Application Requirements
Please note: Incomplete applications will be subject to an additional $50 administrative fee.
Please make sure to complete all sections of the application and include all required supporting
documentation.
1. Candidate must have a High School diploma, GED or higher. Candidate must submit copy of
GED, high school or higher diploma or transcript.
2. Candidate must self-attest to a minimum of two years of recovery from lived-experience in
substance use and/or co-occurring mental health disorders. (See page 10 of the application.)
3. Candidate must have a minimum of 200 hours of direct practice (volunteer or paid) in a peer
recovery support environment.
Supervisor must attest that the candidate has a minimum of 200 hours of direct practice
(volunteer or paid). (See page 10 of the application.)
4. Candidate must provide evidence of earning 60 continuing education contact hours (CEs) of
peer recovery-focused education and training. (See page 3 of the application.)
a. At least 48 hours of peer recovery-focused education and training, including education
in documentation, community/family education, case management, crisis management,
Recovery-Oriented Systems of Care (ROSC), screening and intake, identification of
indicators of substance use and/or co-occurring disorders for referral, service
coordination, service planning, cultural awareness and/or humility, and basic
pharmacology.
b. At least six hours of Ethics education and training within the last six years.
c. At least six hours of HIV/Other Pathogens education and training within the last six
years.
5. Candidate must sign a statement that they have read and adhere to the NAADAC/NCC AP
Peer Recovery Support Specialist Code of Ethics. (See page 10 of the application.)
6. Candidate must submit two references. At least one of the references must be a professional
reference. Both references must accompany the NCPRSS application in sealed envelopes.
(Note: Candidate has option to provide one professional and one personal reference or two
professional references. See pages 4-7.)
7. Candidate must mail application and all supporting documents with the non-refundable
application fee of $235 to:
NCC AP
ATTN: NCPRSS
44 Canal Center Plaza, Suite 301
Alexandria, VA 22314
8. NOTE: A passing score on the National Certified Peer Recovery Support Specialist
examination is required. Registration information for the examination will be pr
ovided
once your credential application is approved. (Testing fee is an additional $150.)
NCC AP NCPRSS Credential Application 01-2019 Page 3 of 11
IV. Education Record
Highest Education Achieved: Please submit a copy of GED, high school or higher diploma or
transcript.
Training Hours Summary: You must submit copies of all education and training certificates and
college transcript(s). All CE certificates must show the title of the training, name of the
presenter/education provider (complete with their signature), number of CEs awarded and date that
the training occurred. You may not apply the same title training more than once every two years. We
ask that you do not submit duplicated CE certificates.
Candidate’s Worksheet of Education and Training:
Education and training hours translate as:
• 1 hour of education/training = 1 CE
• 1 quarter college credit = 10 CEs
• 1 semester college credit = 15 CEs
Below are topics for the required 48 CEs of education/training:
_____Basic Pharmacology
_____Case Management
_____Community/Family Education
_____Crisis Management
_____Cultural Awareness and/or
Humility
_____Documentation
_____Identification of Indicators of Co-
occurring Disorders for Referral
_____Recovery-Oriented Systems of Care
(ROSC)
_____Screening and Intake
_____Service Coordination
_____Services Planning
Summary of Candidate’s Education and Training
_____ Contact hours of peer recovery-focused education and training (48 CEs required)
_____ Undergraduate or graduate CEs
_____ Other education and training CEs
_____ Contact hours of Ethics education and training within the last six years (six CEs are
required)
_____ Contact hours of HIV and other pathogens education and training within the last six years
(six CEs are required)
NCC AP NCPRSS Credential Application 01-2019 Page 4 of 11
V. PROFESSIONAL REFERENCE
Candidate’s Name: _________________________________________________________________
Supervisor’s Name: ________________________________________________________________
Supervisor’s Title: _________________________________________________________________
Company’s Name: _________________________________________________________________
Company’s Address: _______________________________________________________________
Work Phone: ____________________________ Cell Phone: ____________________________
Email Address: ___________________________________________________________________
Length of time as Candidate’s Supervisor: ______________________________________________
Please check the area(s) in which you are certified/licensed:
_____ SUD/Professional Counselor _____ Psychologist
_____ Social Worker _____ Psychiatrist
_____ Mental Health _____ Medical Doctor
_____ Marriage & Family _____ Other: _________________________
(Please specify)
This candidate is applying for the National Certification Commission for Addiction Professionals’
National Certified Peer Recovery Support Specialist credential. Your evaluation is of the utmost
importance to the candidate’s application process.
1
2
3
4
5
N/A
a. Documentation
b. Community/Family Education
c. Case Management
d. Crisis Management
e. Recovery-Oriented Systems of Care (ROSC)
f. Screening and Intake
g. Identify Indicators for SUD and/or Co-occurring
Disorders for referral
h. Service Coordination
i. Service Planning
j. Cultural Awareness and/or Humility
k. Basic Pharmacology
l. Other:
___________________________________________
(please provide)
m. Other:
___________________________________________
(please provide)
NCC AP NCPRSS Credential Application 01-2019 Page 5 of 11
Please complete the following statements:
The candidate is an asset to the field of peer recovery support services because:
The candidate is a liability to the field of peer recovery support services because:
Additional Comments:
____ “I recommend the candidate for certification as a National Certified Peer Recovery Support
Specialist.”
____ “I do not recommend the candidate for certification as a National Certified Peer Recovery
Support Specialist.”
“I hereby certify that all of the information given herein is true and complete to the best of my
knowledge and belief.”
________________________________________________________ _______________
Supervisor’s Signature Date
Please return your reference to the candidate in a sealed envelope.
Reminder: Candidate must submit two references and at least one reference must be a
professional reference.
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NCC AP NCPRSS Credential Application 01-2019 Page 6 of 11
VI. PERSONAL REFERENCE
Candidate’s Name: _________________________________________________________________
Reference’s Name & Title: __________________________________________________________
Address: _________________________________________________________________________
Work Phone: ____________________________ Cell Phone: ____________________________
Email Address: ____________________________________________________________________
Length of time you’ve known the Candidate: _____________________________________________
Please check the area(s) in which you are certified/licensed (not required) if applicable:
_____ SUD/Professional Counselor _____ Psychologist
_____ Social Worker _____ Psychiatrist
_____ Mental Health _____ Medical Doctor
_____ Marriage & Family _____ Other: _________________________
(please specify)
This candidate is applying for the National Certification Commission for Addiction Professionals’
National Certified Peer Recovery Support Specialist credential. Your evaluation is of the utmost
importance to the candidate’s application process.
Please rate the candidate in each area listed below by selecting the column regarding the
candidate’s relationship with you and others. In addressing interpersonal relationships, we
believe that these traits impact client care.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Respect for others
Care and concern for others
Genuineness
Empathy
Flexibility
Judgment
Honesty
Capacity for appropriate confrontation
Sense of immediacy
Other: ________________________________
(please provide)
Other: ________________________________
(please provide)
NCC AP NCPRSS Credential Application 01-2019 Page 7 of 11
Please complete the following statements:
The candidate is an asset to the field of peer recovery support services because:
The candidate is a liability to the field of peer recovery support services because:
Additional Comments:
____ “I recommend the candidate for certification as a National Certified Peer Recovery Support
Specialist.”
____ “I do not recommend the candidate for certification as a National Certified Peer Recovery
Support Specialist.”
“I hereby certify that all of the information given herein is true and complete to the best of my
knowledge and belief.”
________________________________________________________ _______________
Signature Date
Please return your reference to the candidate in a sealed envelope.
Reminder: Candidate must submit two references and at least one reference must be a
professional reference.
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signature
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NCC AP NCPRSS Credential Application 01-2019 Page 8 of 11
VII-a. Career History
In providing your employment history, please list your current position first and work backwards until
you have documented the required minimum of 200 hours of direct practice in a peer recovery support
environment (volunteer or paid). Attach additional pages as needed.
Current Employer: ________________________________________________________________
Address: ________________________________________________________________________
Job title: ________________________________________________________________________
Position held from: (month/year) __________________ to: (month/year) _____________________
Supervisor Name: ______________________________________ Phone: ____________________
Supervisor’s Email Address: ________________________________________________________
Brief job description:
NCC AP NCPRSS Credential Application 01-2019 Page 9 of 11
VII-b. Career History
Previous Employer: _______________________________________________________________
Address: ________________________________________________________________________
Job title: ________________________________________________________________________
Position held from (month/year) ___________________ to (month/year) _____________________
Supervisor Name: ______________________________________ Phone: ____________________
Supervisor’s Email Address: ________________________________________________________
Brief job description:
NCC AP NCPRSS Credential Application 01-2019 Page 10 of 11
VIII. Candidate’s Confirmation of Recovery (Self-Attestation)
“I verify having a minimum of two years of recovery from lived-experience in substance use
and/or co-occurring mental health disorders.”
______________________________________________________ _____________
Applicant’s Signature Date
______________________________________________________ ____________________
Applicant’s Name (please print) Phone
IX. Supervisor’s Verification of Candidate’s Direct & Ethical Practice
“I verify that, to my knowledge, this candidate has a minimum of 200 hours of direct practice
(volunteer or paid) in a peer recovery support environment. In addition, I verify, to the best of
my knowledge, that this candidate engages in ethical peer recovery practice.”
______________________________________________________
Supervisor’s Signature
____
_________
Date
____________________________________________________ ____________________
Supervisor’s Name (please print) Phone
___
________________________________________________________________________________________
Supervisor’s Email Address
X. NAADAC/NCC AP NCPRSS Code of Ethics
All those holding the NCC AP NCPRSS credential are required to adhere to the NAADAC/NCC AP
Peer Recovery Support Specialist Code of Ethics. Ethics code violations may result in disciplinary
actions, including loss of your credential. The full NAADAC/NCC AP Peer Recovery Support
Specialist Code of Ethics is located in full at http://www.naadac.org/ncprss-code-of-ethics.
“I hereby attest that I have read, understand, and will adhere to the NAADAC/NCC AP
Peer Recovery Support Specialist Code of Ethics.”
____________________________________________________
Candidate’s Signature
_____
________
Date:
NCC AP NCPRSS Credential Application 01-2019 Page 11 of 11
XI. Candidate’s Affirmation
“I certify that I meet the eligibility requirements for the National Certified Peer Recovery
Support Specialist (NCPRSS) national credential, and that the information in this application
and its supporting documents is accurate, correct and complete. I also certify that the state
credential/license presented is not encumbered in any manner and that I do not hold a
credential/license from any other state that is or has been subject to criminal or ethical complaint.
The National Certification Commission for Addiction Professionals (NCC AP) is authorized to
contact any institution, organization or individual listed on or included with this application for
verification of my substance use disorders counseling history. I understand that the NCC AP retains
ownership of the NCPRSS credential and may, from time to time, make available credential holder
names and other information to potential service users.”
_______________________________________________________ __________
Candidate’s Signature Date
Note: State licensure/certification is not required for the NCPRSS credential.
Candidate’s Checklist
Completed Personal Data.
Included check/money order or provided credit card information. (The
NCC AP has a no refund
policy for incomplete applications.)
Enclosed copy of GED, High School or higher diploma or transcript.
Enclosed copies of education/training certificates to include at least six hours of ethics training and six
hours of HIV/other pathogens training that took place within the last six years.
Completed Career History Section.
Professional Reference and Personal Reference (or two Professional References) included.
Candidate’s Recovery Self-Attestation.
Supervisor’s Verification of Candidate’s Direct & Ethical Practice.
Signed statement that candidate has read, understands, and will adhere to the NAADAC/NCC AP
NCPRSS Code of Ethics.
Completed Candidate Affirmation.
Application and supporting documentation must be mailed to:
NCC AP - Certification Department
44 Canal Center Plaza, Ste 301
Alexandria, VA 22314
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Completed 21 July 2020

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