Certified Recovery Peer Advocate-Provisional (CRPA-P) Application Form ASAP-New York Certification Board | 5-2020 [email protected]Page 1 of 5 Certified Recovery Peer Advocate-Provisional (CRPA-P) Application Form Please PRINT clearly or type Candidate’s Signature _____________________________________________________ Date _______________________________ NYCB Fee Policy: By signing below, I acknowledge the current fee associated with the CRPA-P certification (listed above) and understand that all fees are non-refundable and may change at any time. For a complete list of NYCB fees, please visit the NYCB website (http://www.asapnys.org/ny-certification-board/). I understand that I am responsible for all fees associated with the certification process at the time of my initial application and that my application will not be processed until payment is received. All fees must be paid by check, money order, or credit card. No cash payments will be accepted. A fee of $35 will be due for all returned checks and a hold will be placed on my application until the original and returned check fees are received by the NYCB. To pay by credit card, please use our online payment portal at https:// events.r20.constantcontact.com/register/eventReg?oeidk=a07egzrna44e90cbb28&oseq=&c=&ch=. * Please note that all incomplete applications and fees paid expire one year after receipt. CRPA-P Fee (All NYCB Fees are Non-Refundable) CRPA-P Application Filing Fee * $100.00 Legal name as found on driver’s license or legal ID: First: M.I. Last: Home Street Address: City: ST: Zip: Email: Cell phone #: Home phone #: CRPA-Provisional and CRPA candidates must be at least 18 years old Date of Birth: I graduated from High School (circle one) Date _________________________ Yes No You must submit a copy of one of the following: High school diploma or transcript showing date of graduation Accredited high school equivalency diploma or certificate Transcript or diploma from accredited institution of higher education
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Certified Recovery Peer Advocate Provisional (CRPA P ...€¦ · 5/4/2020 · (CRPA-P) Application Form . ASAP-New York Certification Board | 5-2020. [email protected] . Page 3
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Certified Recovery Peer Advocate-Provisional (CRPA-P) Application Form
As you work toward full CRPA certification, please note that work and supervision which occurred in a treatment setting while you were actively in treatment in that setting will not meet the requirements.
I have read the above CRPA-Provisional requirements and I understand that I MUST MEET ALL CURRENT REQUIREMENTS in order to be eligible to become certified as a CRPA-Provisional.
Candidate’s Signature _________________________________________________ Date ___________________________
Requirements for Certification
Certified Recovery Peer Advocate-Provisional
Education
Candidate must provide a copy of one of the following:
• High school diploma or transcript showing date of graduation OR
• Accredited high school equivalency diploma or certificate OR
• Transcript or diploma from accredited institution of higher education
Peer Recovery Training
Candidates must submit copies of training certificates confirming successful
completion of 46 hours of NYCB-approved training which includes the equivalent of:
• 10 hours Advocacy
• 10 hours Mentoring/Education
• 10 hours Recovery/Wellness Support
• 16 hours Ethical Responsibility in the Peer Recovery role
Role Experience:
CRPA-Provisional
In March 2020 the New York Certification Board removed the requirement that a
candidate must currently be working in a peer recovery role (paid or volunteer)
under appropriate supervision/management. No work experience is currently
required.
NYCB Code of Ethical Conduct
Candidate must agree to read and abide by the NYCB Code of Ethical Conduct. This
handbook may be downloaded at our website: http://www.asapnys.org/ny-
certification-board/. Candidate must endorse and sign the NYCB Code of Ethical
Conduct statement (page 4).
Application Expiration If any application remains incomplete and on hold for one year or more, all fees paid will expire.
Annual Renewal Requirement The CRPA-P certification is non-renewable and expires 24 months after effective
date.
UPGRADE REQUIREMENT
CRPA-Provisional is issued for only 24 months.
You must upgrade and pass the exam within 24 months
to remain certified.
CRPA-Provisional certification is non-renewable.
Candidate must complete all CRPA requirements and submit an Upgrade to CRPA
application along with the $50 upgrade and $80 exam fees ($130) at least 45 days
prior to expiration of their CRPA-Provisional certification date (24 months):
500 hours of peer recovery work experience (paid or volunteer) which includes
25 hours of supervision (confirmed by appropriate supervisor).
Candidate may take the exam anytime during the two-year certification period
as long as the exam fee has been paid. NYCB staff must first pre-register eligible
candidates in order for candidate to pick date and place of exam.
Pass the computer-based IC&RC Peer Recovery Exam.
Upgrade to CRPA application must be approved by the NYCB.
Please make sure you complete all of the following items in order to ensure timely
processing of your application.
Check off each item as it is completed. Your application will not be processed until you
submit the filing fees and all of the following items have been received:
Candidate’s Signature _________________________________________________ Date ___________________________
I have completed all of the above items and have submitted them according to the NYCB submission
instructions and current CRPA-Provisional requirements.
Pay the application filing fee of $100.00. You may pay by check or money order (payable to NYCB). You
may also pay by credit card for all payments required for CRPA-P certification using the NYCB Peer Certification Payment Portal at https://events.r20.constantcontact.com/register/eventReg?
oeidk=a07egzrna44e90cbb28&oseq=&c=&ch=. You can only select one option for payment. If you
don't see a choice relevant for you, please email [email protected].
Review your entire CRPA-P Application. Fill out, sign, date, and initial where asked. Electronic signatures
and initials will be accepted. Submit only numbered pages 1-5.
Include a copy of your high school diploma OR a high school transcript showing date of graduation OR accredited equivalency OR transcript or diploma from accredited institution of higher education. If your
name has changed since this document was issued, provide a copy of a legal document clearly showing
the change from one name to another (such as a marriage license or divorce decree).
Include copies of training certificates confirming successful completion of 46 hours of NYCB-approved
training. This training includes the equivalent of: Peer Advocacy (10 hours), Peer Mentoring/Education
(10 hours), Peer Recovery/Wellness Support (10 hours), and Ethical Responsibility for Peers (16 hours).
Download a copy of the NYCB Code of Ethical Conduct from our website. Read it before you sign and date the NYCB Code of Ethical Conduct statement on page 4. Certificants are required to abide by the
provisions of the code or face censure by NYCB.
Read, sign, and date the Authorization to Obtain Information Statement on page 4.
Read and initial each box, then sign and date the CRPA-Provisional Attestation form on page 5.
Make a copy of the entire packet for your records prior to submitting to NYCB.
Familiarize yourself with the four steps toward certification found on page 6.
Submit your application only when you have filled out, signed, dated, and initialed each page
A. I hereby attest that all of the information given is true and complete to the best of my knowledge and belief. I
understand that falsification of any portion of this application will result in my being denied certification or revocation of same, upon discovery.
B. I acknowledge the right of the NYCB to verify the information in this application or to seek further information from employers, schools, or persons mentioned within.
C. I have read, understand, and agree to act in accordance with the NYCB Code of Ethical Conduct (2012) and the NYCB Code
of Ethical Conduct - Disciplinary Procedures (2012) available on the NYCB’s website at http://www.asapnys.org/ny-
certification-board/.
D. I will hold NYCB, Inc., its Board members, officers, agents, and staff free from any civil liability for damages or complaints by reason of any action that is within their scope and arising out of the performance of their duties which they, or any of them, may take in connection with any examination, and/or failure of the Board to bestow upon me certification with the NYCB or any other entity.
E. I understand that upon acceptance of my application, additional fees may be due and payable including exam fees,
renewal fees, etc. and that all NYCB fees are non-refundable without exception.
By signing in this box, I agree to all aspects of the statement above.
Candidate’s Name (print): Date: __________________
I hereby authorize the NYCB to request and receive all records and/or information in any way relating to my application for a NYCB credential. I understand that this includes, but is not limited to, verbal or written contacts with my employer(s), colleagues, academic and training institutions, and/or other persons or organizations having pertinent information related to the review of my application. This is a waiver of my privilege that may otherwise exist in respect to the disclosure of such information. I understand that this authorization will expire one year after certification lapses or when my certification expires, once NYCB is notified of my intent not to renew. I further understand that the status of any NYCB credential is public record and may be shared by NYCB and is available on the NYCB website, including effective date, expiration date and certification type. I further understand that if my NYCB credential is sanctioned in any way including revocation or suspension that this information is public.
By signing in this box, I agree to all aspects of the statement above.
Candidate’s Name (print): Date: __________________
Personal information in this application is considered confidential and may only be disclosed with written consent, a court-ordered subpoena, or conditions specified in New York State law with respect to the protection of persons with special needs. The sole exception to this policy permits ASAP-NYCB to release applicant contact information (i.e., telephone numbers, email addresses, work or home addresses) to Federal or State authorities in the event of a national or regional disaster/emergency, unless the applicant indicates below that he/she does not want personal contact information released.
Check here if you would prefer not to have your personal contact information released in the event of a regional of national emergency. Certification award is not contingent on providing permission to share this information.