Application for CPRS Form can be completed and saved. You may then print the appropriate pages to submit to MABPCB. past or current MABPCB credentials held: CCDC CCS CCJP CCDP Other ___________ □ □ □ □ □ Date: Date of Birth: Male Female □ □ Name: SSN: Home Address: City: State: Zip: County: Home Phone: Email: (required) Employer: Employer Address: City: State: Zip: County: Work Phone: Ext: Dates Employed Peer Recovery Hours per Week: – Support Services : Immediate Title: Supervisor: Email: High School: Name on Diploma: If MAPCB needs to contact you, please indicate your preference: Email Phone □ □ Why are you pursuing certification? (required) _________________________________________________________________________________________________ I hereby attest that the applicant is working in a position where a minimum of 51% of his/her time is spent providing direct peer recovery support services (coaching, mentoring, etc.). The applicant has primary responsibility for providing peer recovery support services (coaching, mentoring, etc.).in individual and/or settings, preparing recovery or wellness plans, documenting client progress and is supervised by an individual who is knowledgeable in behavioral health or recovery support issues. ____________________________________________________ Supervisor’s Signature
Application for CPRS Form can be completed and saved. You may then print the appropriate pages to submit to MABPCB. past or current MABPCB credentials held: □ CCDC □ CCS □ CCJP □ CCDP □ Other ___________ Date: Date of Birth: □ Male □ Female Name: SSN: Home Address: City: State: Zip: County: Home Phone: Email: (required) Employer: Employer Address: City: State: Zip: County: Work Phone: Ext: Dates Employed – Peer Recovery Support Services : Hours per Week: Immediate Supervisor: Title: Email: High School: Name on Diploma: If MAPCB needs to contact you, please indicate your preference: □ Email □ Phone Why are you pursuing certification? (required) _________________________________________________________________________________________________ I hereby attest that the applicant is working in a position where a minimum of 51% of his/her time is spent providing direct peer recovery support services (coaching, mentoring, etc.). The applicant has primary responsibility for providing peer recovery support services (coaching, mentoring, etc.).in individual and/or settings, preparing recovery or wellness plans, documenting client progress and is supervised by an individual who is knowledgeable in behavioral health or recovery support issues. ____________________________________________________ Supervisor’s Signature
cprs-manual-application-revised-20161.docx