{"id":15694,"date":"2020-04-23T15:08:15","date_gmt":"2020-04-23T22:08:15","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=15694"},"modified":"2020-04-25T09:46:58","modified_gmt":"2020-04-25T16:46:58","slug":"professional-reference-form","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/1702241604-2\/professional-reference-form\/","title":{"rendered":"Professional Reference Form"},"content":{"rendered":"\n<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-46\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-46\" value=\"1777448114\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"46\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Applicant Information <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1216\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Credential Applicant<\/div><span class=\"vfb-help-block\">Please enter the name of the person seeking a professional credential with Breining Institute, who has requested that you provide a professional reference.<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1184\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1185\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1185\" class=\"vfb-control-label\">Applicant Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1185\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1185\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1187\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1187\" class=\"vfb-control-label\">City \/ State: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please enter the name of the city and State where the credential applicant currently works or resides. If you do not know the city and State where the applicant currently works or resides, please include the last known city and State.<\/span><input id=\"vfb-field-1187\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1187\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1222\"><label for=\"vfb-field-1222\" class=\"vfb-control-label\">Breining Credentials sought <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please select the Breining Institute credential(s) being applied for by the Applicant.<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1222[0]\" value=\"1\">Registered Addiction Specialist (RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[1]\" value=\"1\">Registered Addiction Specialist - Level II (RAS II)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[2]\" value=\"1\">Registered Addiction Specialist - Level III (RAS III)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[3]\" value=\"1\">Masters Level - Registered Addiction Specialist (M-RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[4]\" value=\"1\">Clinical Supervisor Credential (CSC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[5]\" value=\"1\">Master Counselor in Addictions (MCA)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[6]\" value=\"1\">Certified Womens Treatment Specialist (CWTS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[7]\" value=\"1\">Medication-Assisted Treatment Counselor (MATC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[8]\" value=\"1\">Forensic Addiction Counselor (FAC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[9]\" value=\"1\">Certified Co-occurring Disorders Specialist (CCDS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[10]\" value=\"1\">Certified Case Manager Interventionist (CCMI)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1222-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1222\" type=\"checkbox\" name=\"vfb-field-1222[11]\" value=\"1\">Certified Case Manager Interventionist - Masters Level (CCMI-M)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Reference Information <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1217\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Professional Reference Information<\/div><span class=\"vfb-help-block\">Here we are requesting information about you, in order that we know who is providing the Professional Reference, and so that we will be able to contact you if we need follow-up information about the Credential Applicant.<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1221\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1218\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1218\" class=\"vfb-control-label\">Your Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1218\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1218\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1207\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1207\" class=\"vfb-control-label\">Name of your current employer: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">If you are not currently employed, you may answer \"not applicable\"<\/span><input id=\"vfb-field-1207\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1207\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1223\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1223\" class=\"vfb-control-label\">Address of your current employer: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please include street address, city, State or Province, and ZIP code or Country code. If you are not currently employed, you may answer \"not applicable\" here.<\/span><input id=\"vfb-field-1223\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1223\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1209\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1209\" class=\"vfb-control-label\">Employer website: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">If current employer does not have a website, you may include its social media page (such as Facebook, LinkedIn, or similar page), or you may include \"Not applicable\" as an answer.<\/span><input id=\"vfb-field-1209\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1209\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1192\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1192\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please enter your current Email address, so that we will be able to contact you if we have further questions about this applicant.<\/span><input id=\"vfb-field-1192\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-1192\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1193\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1193\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please re-enter your email address here<\/span><input id=\"vfb-field-1193\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-1192\" type=\"email\" name=\"vfb-field-1193\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField1194\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1194\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1194\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-1194\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1219\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1219\" class=\"vfb-control-label\">Your professional license(s) or certification(s)<\/label><div><span class=\"vfb-help-block\">If you currently hold professional healthcare licenses or certifications, please list them here.<\/span><input id=\"vfb-field-1219\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1219\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1196\"><label for=\"vfb-field-1196\" class=\"vfb-control-label\">Current Breining Credentials<\/label><div><span class=\"vfb-help-block\">If applicable, please select all credentials that you currently hold with Breining Institute.<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[0]\" value=\"1\">Registered Addiction Specialist (RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[1]\" value=\"1\">Registered Addiction Specialist - Level II (RAS II)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[2]\" value=\"1\">Registered Addiction Specialist - Level III (RAS III)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[3]\" value=\"1\">Masters Level - Registered Addiction Specialist (M-RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[4]\" value=\"1\">Clinical Supervisor Credential (CSC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[5]\" value=\"1\">Master Counselor in Addictions (MCA)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[6]\" value=\"1\">Certified Womens Treatment Specialist (CWTS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[7]\" value=\"1\">Medication-Assisted Treatment Counselor (MATC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[8]\" value=\"1\">Forensic Addiction Counselor (FAC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[9]\" value=\"1\">Certified Co-occurring Disorders Specialist (CCDS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[10]\" value=\"1\">Certified Case Manager Interventionist (CCMI)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1196-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1196\" type=\"checkbox\" name=\"vfb-field-1196[11]\" value=\"1\">Certified Case Manager Interventionist - Masters Level (CCMI-M)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Reference Statement <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1220\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1224\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1224\" class=\"vfb-control-label\">How do you know the applicant? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please let us know how you know the applicant. Did or do you supervise the applicant? Did or do you work in the same institution or agency? Have you worked with or do you know the person as a colleague in your profession?<\/span><textarea id=\"vfb-field-1224\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"10\" name=\"vfb-field-1224\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1203\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1203\" class=\"vfb-control-label\">Please provide your reference statement here. <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please use this space to explain why you believe that the Applicant should be awarded the credential or credentials for which she or he is applying.<\/span><textarea id=\"vfb-field-1203\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"10\" name=\"vfb-field-1203\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1213\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1213\" class=\"vfb-control-label\">Are you ready to submit your reference?<\/label><div class=\"\"><h3><span style=\"color: #008000;\">We appreciate you taking the time to provide this reference for the person seeking to be awarded a professional credential from Breining Institute.<\/span><\/h3>\n<h3><span style=\"color: #008000;\">If you are satisfied with your response, please select the &#8220;<strong>Submit<\/strong>&#8221; button below, and this Professional Reference Form will be submitted to Breining Institute.<\/span><\/h3>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField1214\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1214\" class=\"vfb-control-label\">Captcha <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"g-recaptcha\" data-sitekey=\"6LdWgN0UAAAAAM_hb1SqmzT2DP4J1X289K2epOVA\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField1215\"><button id=\"vfb-field-1215\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/section><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":2885,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-15694","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15694","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/comments?post=15694"}],"version-history":[{"count":2,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15694\/revisions"}],"predecessor-version":[{"id":15722,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15694\/revisions\/15722"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/2885"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=15694"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}