CPSS Application - Delaware Certification Board

CPSS
Application
DCB CPSS Application – Revised December 2014 CertifiedPeerSupport
Specialist
1
DIRECTIONS/CHECKLIST
□ Documentation of high school diploma/GED or official college transcript required sent directly from college/university to the DCB Office. It is recommended you request transcripts approximately three weeks prior to sending in your application. □ Certificates of attendance for trainings (copies, not originals). □ Current job description signed and dated by applicant and supervisor. □ Documentation of paid or volunteer peer support experience. Acceptable documentation includes a letter (on company letterhead) from current and/or previous employer(s) verifying your duties and dates employed. □ Sign and date the Code of Ethical Conduct. □ Release form notarized. □ Letter of recommendation from current or former supervisor. □ Documentation as a person with lived experience. Documentation should be a written statement about the lived experience of no more than one page in length. □ Fee of $100. May be paid by check/money order (payable to DCB) or Visa, MasterCard or Discover. One‐half of fee is refundable if application is denied or cancelled prior to the exam – no refund if application is denied or cancelled after exam. If an employer or organization is covering the cost of your application fee, they must include the applicants name with the payment. Failure to include the applicants name will result in delay in approval of the application. If there are any problems with the application, you will be notified by email. Applications are open for a period of one year after the date of review. If an applicant fails to fulfill all certifications requirements within that year, the application will be closed and no refund will be issued. Keep a photocopy of the entire application. Applicants can email, mail or fax completed application, copies of certificates of attendance, attachments, and fee to: DCB 298 S. Progress Avenue Harrisburg, PA 17109 Phone: (717) 540‐4456 Fax: (717) 540‐4458 Website: www.delawarecertificationboard.org Email: [email protected] DCB CPSS Application – Revised December 2014 2
REQUIREMENTS FOR CPSS
Experience 
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1000 total hours of supervised volunteer or paid experience providing peer support services. 500 of the 1000 hours must have been gained within one year prior to the candidate applying for the credential. The remaining 500 hours must have been gained within three years of applying for the credential. All experience must be supervised. Education & Training 
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High school diploma/GED. 54 hours of peer training to include all current domains. Training must be the DSAMH approved peer curriculum or training that is submitted to and approved by DCB prior to candidate applying for the credential. Education is defined as formal, structured instruction in the form of workshops, seminars, institutes, in‐
services, college/university credit courses and DCB approved distance education. There is no limit to the number of distance learning/online education that can be submitted. Three college credits are equivalent to 45 hours. Education, as defined above, applicant provides to other professionals may also be used providing it is verified in writing by sponsoring school or agency. Examination 
Pass the Certified Peer Support Specialist Examination. Other 
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Signed and dated Code of Ethical Conduct. Signed, dated and notarized Release. Current job description dated and signed by supervisor and candidate. Candidate must either live or work in DE at time of application. CPSS Domains: History of Consumer Survivor Movement; Recovery; Peer Support; Boundaries/Ethics; Self‐
Disclosure; Telling Your Recovery Story; Communication; WRAP; Positive Self‐Talk; Client’s Rights; Olmstead Act/DOJ Settlement; Stigma; Substance Abuse/Co‐Occurring Disorders; Cultural Uniqueness; Suicide Prevention; Wellness; Trauma; Understanding Mental Health & Mental Illness; Confidentiality; Advocacy; Spirituality; Crisis Prevention/Intervention; Creativity. Fees Certification: $100 (fee must accompany application and materials) Retest: Exam Cancellation: $ 50 $ 50 CERTIFICATION TIME PERIOD CPSS encompass two calendar years and may be recertified. Two dates, date of issue and valid through, will appear on the certificate along with a certification number. APPEAL PROCESS The purpose of appeal is to determine if DCB accurately, adequately and fairly reviewed applicant's file. A letter requesting an appeal must be made to DCB in writing within 30 days of the notification of the board's action. A person shall be considered notified three days after the relevant date of mailing. The written appeal will be sent to the Executive Committee who in turn will thoroughly review the entire application and materials to determine DCB CPSS Application – Revised December 2014 3
whether or not applicant should have been denied approval. Applicant will be notified in writing as to the findings of the Executive Committee. EXAMINATION INFORMATION Type: This credential requires successful completion of the Certified Peer Support Specialist exam which is offered as a paper and pencil exam. Two and a quarter hours are permitted to complete the 100 question, multiple choice exam. Candidates will be notified by DCB, once application for certification is approved, on scheduling for the exam. Content: Questions in the exam were derived from the DSAMH approved peer curriculum training. Candidate Guide: Candidate Guides will be sent to candidates prior to exam scheduling. Candidate Guides are also available from the DCB website at www.delawarecertificationboard.org. Candidate Guides provide information about the examination process. Dates: The exam is offered quarterly. Candidates will receive information from DCB on dates, times and locations for the exam once application for certification is approved. Special Situations: Individuals with disabilities and/or religious obligations that require modifications in exam administration may request specific procedure changes, in writing, to DCB no fewer than 60 days prior to the scheduled exam date. With the written request, candidate must provide official documentation of the disability or religious issue. Contact DCB on what constitutes official documentation. DCB will make arrangements for appropriate modifications to its procedures when documentation supports this need. Cancellation/Rescheduling Policy: The exam fee of $50 will be forfeited unless a minimum of 10 days’ notice is given to DCB to cancel a reservation. Retest: Candidates will be sent retest instructions from DCB. Applicant must the take the exam within one year to keep the application active. Additionally, candidates will have three (3) opportunities to re‐take an examination beyond their original first failed examination. If a candidate re‐tests their allotted three times and fails on their third and final opportunity, the candidate must submit a plan of study to DCB and wait a mandatory one‐year from the date of the final failed examination before they will be permitted to re‐test again. RECERTIFICATION To maintain the high standards of this credential and to assure continuing awareness of new knowledge in the field, DCB requires recertification every two years. To be recertified as a CPSS, an individual must: 1. Hold a current and valid certificate issued by DCB; 2. Acquire 20 hours of training/education to include four hours in peer specific ethics/boundaries; four hours in peer support and recovery; two hours in trauma; and two hours in creativity – all of which must have been received within the two year recertification cycle; 3. Verify that you have reviewed, read and will uphold by practice the DCB Code of Ethical Conduct for professional behavior; 4. Complete an application and pay the recertification fee of $50. LAPSED CERTIFICATION The completed recertification application should be received at DCB prior to the expiration date. If the application is incomplete, applicant will be notified by phone or email depending on what has been indicated by applicant. A credential is valid for a two year period. If your credential lapses, you have 12 months from your expiration date to recertify. After 12 months, you must re‐apply for your credential(s) and complete all the requirements for initial certification. DCB CPSS Application – Revised December 2014 4
APPLICATION FOR CPSS
Please type or print only. Date: Date of Birth: □ Male □ Female
Name: SSN:
Please print your name as it should appear on your certificate Home Address: City: State:
Zip: County: Home Phone:
Email:
(required) College/University: Name on Transcript: Employer: Position/Title:
Employer City: Employer Zip: Employer State: Work Phone:
Ext: Dates Employed: Hours per Week: Immediate Supervisor: Title: Phone: Email: I hereby attest that the above‐named candidate is providing peer support services in a paid or voluntary capacity and that this experience is supervised. ____________________________________________________ Supervisor’s Signature Why are you pursuing certification? (required) Fee: $100 □ Check/MO (payable to DCB) □ Credit Card (Visa, MasterCard or Discover) ‐ ‐ ‐ 3‐digit code: Exp. Date: Billing address: (If different than Home Address) Name on Card: DCB CPSS Application – Revised December 2014 5
PREVIOUS RELEVANT EMPLOYMENT, IF APPLICABLE Include letter (on company letterhead) from previous employer verifying your duties and dates employed. Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
Name of Employer: City: State:
Your Title: Hours per Week:
Dates Employed: Immediate Supervisor:
DCB CPSS Application – Revised December 2014 6
CODE OF ETHICAL CONDUCT The primary responsibility of Certified Peer Support Specialists is to help individuals achieve their own needs, wants, and goals. Certified Peer Support Specialists will be guided by the principle of self‐determination for all. Certified Peer Support Specialists will maintain high standards of personal conduct. Certified Peer Support Specialists will also conduct themselves in a manner that fosters their own recovery. Certified Peer Support Specialists will openly share with consumers and colleagues their recovery stories from mental illness and will likewise be able to identify and describe the supports that promote their recovery. Certified Peer Support Specialists will, at all times, respect the rights and dignity of those they serve. Certified Peer Support Specialists will never intimidate, threaten, harass, use undue influence, physical force or verbal abuse, or make unwarranted promises of benefits to the individuals they serve. Certified Peer Support Specialists will not practice, condone, facilitate or collaborate in any form of discrimination on the basis of ethnicity, race, sex, sexual orientation, age, religion, national origin, marital status, political belief, mental or physical disability, or any other preference or personal characteristic, condition or state. Certified Peer Support Specialists will advocate for those they serve that they may make their own decisions in all matters when dealing with other professionals. Certified Peer Support Specialists will respect the privacy and confidentiality of those they serve. Certified Peer Support Specialists will advocate for the full integration of individuals into the communities of their choice and will promote the inherent value of these individuals to those communities. Certified Peer Support Specialists will be directed by the knowledge that all individuals have the right to live in the least restrictive and least intrusive environment. Certified Peer Support Specialists will not enter into dual relationships or commitments that conflict with the interests of those they serve. Certified Peer Support Specialists will never engage in sexual/intimate activities with the consumers they serve. Certified Peer Support Specialists will not abuse substances under any circumstance. Certified Peers Support Specialists will keep current with emerging knowledge relevant to recovery, and openly share this knowledge with their colleagues. Certified Peer Support Specialists will not accept gifts of significant value from those they serve. Signature: __________________________________________________ Date: _______________________ DCB CPSS Application – Revised December 2014 7
RELEASE (must be notarized below) I hereby request that DCB 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 DCB Code of Ethical Conduct; I hereby 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 manuscripts and other personal information relative to my certification. Falsification of any records or documents in my application 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 DCB to officers, members, and staff of the aforementioned Board; I consent to authorize DCB to gather information from third parties regarding continuing education and employment and understand that such communication shall be treated as confidential; Allegations of ethical misconduct reported to DCB before, during, or after application for certification is made will be investigated by DCB and could result in the nullification of the application or denial or revocation of certification. Signature:__________________________________________ Date:__________________________________ On this the ______ day of ___________________, 201_____, by me _____________________________________ a notary public, the undersigned officer, personally appeared: _________________________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that she/he executed the same for the purposes therein contained. In witness whereof, I hereby set my hand and official seal. Sworn and subscribed before me this ______ day of _________________________, 201_____. ______________________________________________________ SEAL: Notary Public DCB CPSS Application – Revised December 2014 8

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