{"id":15733,"date":"2020-04-25T09:53:39","date_gmt":"2020-04-25T16:53:39","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=15733"},"modified":"2020-04-26T07:53:21","modified_gmt":"2020-04-26T14:53:21","slug":"professional-credential-application-form","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/1702241604-2\/professional-credential-application-form\/","title":{"rendered":"Professional Credential Application Form"},"content":{"rendered":"\n<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-45\" 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-45\" value=\"1777118276\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"45\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Credential <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1169\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1170\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1170\" class=\"vfb-control-label\"><\/label><div class=\"\"><div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<h3><strong><span style=\"color: #008000;\">Please complete this online form carefully and completely<\/span><\/strong><\/h3>\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<ul>\n<li>In order to process your application in a timely manner, we will appreciate you providing all of the information requested.<\/li>\n<li>To submit qualifying documentation, you may do so by uploading it using this online application, or you may sent it to us separately by email, using the following email address:\n<ul>\n<li>Email: college@breining.edu<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1179\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1179\" class=\"vfb-control-label\"><\/label><div class=\"\"><p><strong><span style=\"color: #008000;\">Which internationally-awarded Breining Institute credential are you seeking?<\/span><\/strong><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1173\"><label for=\"vfb-field-1173\" class=\"vfb-control-label\">Please make your selection here. <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">If you are seeking multiple credentials, you will need to submit a separate application for each credential.<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1173[0]\" value=\"1\">Registered Addiction Specialist (RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[1]\" value=\"1\">Advanced RAS - Level II (RAS II)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[2]\" value=\"1\">Advanced RAS - Level III (RAS III)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[3]\" value=\"1\">Masters Level - RAS (M-RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[4]\" value=\"1\">Clinical Supervisor Credential (CSC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[5]\" value=\"1\">Master Counselor in Addictions (MCA)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[6]\" value=\"1\">Certified Women's Treatment Specialist (CWTS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[7]\" value=\"1\">Medication-Assisted Treatment Counselor (MATC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[8]\" value=\"1\">Forensic Addictions Counselor (FAC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[9]\" value=\"1\">Certified Co-occurring Disorders Specialist (CCDS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[10]\" value=\"1\">Certified Case Manager Interventionist - Intern (CCMI-Intern)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[11]\" value=\"1\">Certified Case Manager Interventionist - Associate (CCMI-A)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-12\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[12]\" value=\"1\">Certified Case Manager Interventionist (CCMI)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1173-13\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1173\" type=\"checkbox\" name=\"vfb-field-1173[13]\" 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\">Applicant Information <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1167\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 1. Applicant Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1123\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1124\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1124\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1124\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1124\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1125\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1125\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1125\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1125\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1126\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1126\" class=\"vfb-control-label\">City: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1126\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1126\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1127\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1127\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1127\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1127\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1128\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1128\" class=\"vfb-control-label\">ZIP Code or Country Code: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1128\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1128\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-select\" id=\"vfbField1129\"><label for=\"vfb-field-1129\" class=\"vfb-control-label\">Country:<\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-1129\" class=\"vfb-form-control\" placeholder=\"\" name=\"vfb-field-1129\"><option value=\"United States\">United States<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1130\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1130\" class=\"vfb-control-label\">Country (if not the United States):<\/label><div><input id=\"vfb-field-1130\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1130\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1131\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1131\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1131\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-1131\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1132\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1132\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1132\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-1132\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField1133\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1133\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1133\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-1133\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1134\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1134\" class=\"vfb-control-label\">Secondary Phone Number<\/label><div><input id=\"vfb-field-1134\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1134\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1135\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1135\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1135\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1135\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1365\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1365\" class=\"vfb-control-label\">Social Security Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Only include the LAST FOUR DIGITS of your Social Security Number. We will use this to verify your identity when communicating with you. If you do not have a Social Security Number, then provide the last four digits of other government identification.<\/span><input id=\"vfb-field-1365\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1365\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Documentation <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1168\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Documentation<\/div><span class=\"vfb-help-block\">In this section, please provide information about your qualifications for the credential you are seeking.\r\n\r\nYou may upload the requested documents using the buttons on this page, or you may send us the documents by email, FAX or postal mail, using these addresses below:<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1140\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1153\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1153\" class=\"vfb-control-label\">Email address<\/label><div class=\"\"><p>Administration@Breining.edu<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1155\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1155\" class=\"vfb-control-label\">Mailing Address<\/label><div class=\"\"><p>Breining Institute &#8211; Admissions Office, 8894 Greenback Lane, Orangevale, California 95662-4019<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1154\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1154\" class=\"vfb-control-label\">Facsimile Number<\/label><div class=\"\"><p>916-987-8823<\/p>\n<p>PLEASE NOTE: Your current photo may not be sent by FAX. It must be sent by using the link on this page, by email, or by postal mail.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1268\"><label for=\"vfb-field-1268\" class=\"vfb-control-label\">Specialty Course Completion <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please select the Breining Institute specialty course you have completed which is a requirement for the credential you are seeking. <\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1268[0]\" value=\"1\">40-hour Clinical Supervisor Education Course<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[1]\" value=\"1\">40-hour Women's Treatment Counselor Education Course<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[2]\" value=\"1\">40-hour Co-occurring Disorders Education Course<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[3]\" value=\"1\">40-hour MAT Counselor Education Course<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[4]\" value=\"1\">40-hour Forensic Counselor Education Course<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[5]\" value=\"1\">125-hour Certified Case Manager Interventionist Training Modules<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1268-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1268\" type=\"checkbox\" name=\"vfb-field-1268[6]\" value=\"1\">I have not yet completed the required course<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1265\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1265\" class=\"vfb-control-label\">Clinical Experience<\/label><div class=\"\"><p>Have the Clinical Experience Verification Form completed and submitted by authorized representative(s) from your employer(s). The link to this Form is on the information page of the Credential you are seeking.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1266\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1266\" class=\"vfb-control-label\">Professional Reference<\/label><div class=\"\"><p>Have the Professional Reference Form completed and submitted by a person with knowledge of your work. The link to this Form is on the information page of the Credential you are seeking.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1259\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1259\" class=\"vfb-control-label\">Degree Verification<\/label><div><span class=\"vfb-help-block\">If applicable, list your degree(s) here, and then upload or send us a copy of your diploma or transcripts.<\/span><input id=\"vfb-field-1259\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1259\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField1152\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1152\" class=\"vfb-control-label\">Degree Upload<\/label><div><span class=\"vfb-help-block\">You may upload one PDF document here, which must be no larger than 5 MB. If you are unable to upload the document, please send it to us by email, FAX or by postal mail.<\/span><input id=\"vfb-field-1152\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf\" type=\"file\" name=\"vfb-field-1152\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1260\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1260\" class=\"vfb-control-label\">Current License or Certification<\/label><div><span class=\"vfb-help-block\">If applicable, list your relevant license(s) or certification(s) here, and then upload or send us a copy of them.<\/span><input id=\"vfb-field-1260\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1260\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField1262\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1262\" class=\"vfb-control-label\">License or Certification Upload<\/label><div><span class=\"vfb-help-block\">You may upload one PDF document here, which must be no larger than 5 MB. If you are unable to upload the document, please send it to us by email, FAX or by postal mail.<\/span><input id=\"vfb-field-1262\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf\" type=\"file\" name=\"vfb-field-1262\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField1263\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1263\" class=\"vfb-control-label\">Current Photograph Upload<\/label><div><span class=\"vfb-help-block\">Upload a current photo of you, in PDF format, which must be no larger than 5 MB. If you are unable to upload the picture, please send it to us by email or by postal mail. Do not send a photo by FAX.<\/span><input id=\"vfb-field-1263\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf\" type=\"file\" name=\"vfb-field-1263\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Application Submission <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1181\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1183\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1183\" class=\"vfb-control-label\">By submitting this Application, you agree to comply with this Code of Ethics:<\/label><div class=\"\"><p>As a an alcohol and other drug \/ substance use disorders (AOD\/SUD) professional, I will comply with this Code of Ethics and do affirm:<\/p>\n<ul>\n<li>That my primary goal is recovery for the client and the client\u2019s family, through conducting my role \u2028as a counselor and\/or supervisor in a professional and caring manner.<\/li>\n<li>That I have a total commitment to provide the highest quality of supervision to those whom I am \u2028committed to providing supervision. That I shall not provide services beyond the terms and \u2028conditions of my professional certifications and\/or licenses.<\/li>\n<li>That I shall evidence a genuine interest in all of the individuals that are counseled and\/or supervised by me, and do \u2028hereby dedicate myself to the best interest of my agency and clients, and to help them help \u2028themselves.<\/li>\n<li>That I shall maintain at all times an objective, professional relationship with all of my clients.<\/li>\n<li>That I shall adhere to the Rule of Confidentiality with regard to all records, material and knowledge \u2028concerning my client, and shall protect his\/her rights to confidentiality in accord with Code of \u2028Federal Regulations, Title 42 sections 2.1 through 2.67(1) and any other applicable regulations.<\/li>\n<li>That I shall cooperate with complaint investigation and supply information requested during such \u2028complaint investigations, subject to the confidentiality provisions cited above.<\/li>\n<li>That I shall not in any way discriminate between clients or fellow professionals on the basis of race, \u2028religion, age, gender, disability, national ancestry, sexual orientation or economic condition.<\/li>\n<li>That I shall respect the rights and views of my fellow counselors and other addiction professionals. \u2028I will not verbally, physically or sexually harass, threaten, or abuse any program participant, patient, \u2028client or fellow addiction professional.<\/li>\n<li>That I shall maintain respect for institutional policies and management within agencies, and will \u2028take the initiative toward improvement of such policies and management when it will better serve \u2028the interests of my clients.<\/li>\n<li>That I have a continuing commitment to assess my own personal strengths, limitations, biases and \u2028effectiveness.<\/li>\n<li>That I shall continuously strive for self-improvement and professional growth through further \u2028education and training.<\/li>\n<li>That I have an individual responsibility for my own conduct in all areas, including, but not limited to, \u2028the use of mood-altering drugs. I shall not provide supervision, counseling or education services while under the influence of any amount of alcohol or illicit drugs (not including drugs or medication prescribed by a physician or other person authorized to prescribe drugs, used in the dosage and frequency prescribed; nor including over-the-counter medications used in the dosage and frequency described on the box, bottle or package insert).<\/li>\n<li>That I have an individual responsibility for myself in regard to sexual conduct and\/or contact with fellow counselors, supervisors, clients, and clients, and shall not engage in sexual conduct with current program participants, patients or clients.<\/li>\n<li>These things I pledge to my professional peers and to my clients.<\/li>\n<li>I hereby pledge to comply with this Code of Ethics, as well as to comply with a consistent code of \u2028conduct that may be applicable to a recovery or treatment program with which I may be affiliated.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Attestation<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1163\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1164\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1164\" class=\"vfb-control-label\"><\/label><div class=\"\"><p>By submitting this form, I attest that the information I have provided above is true and authentic. I understand that if at any time it is determined that the information provided is materially misrepresented, any fees which have been paid will be forfeited, and certifications, degrees and\/or credentials may be revoked.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-signature\" id=\"vfbField1269\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1269\" class=\"vfb-control-label\">Signature <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please carefully use this space to sign your name.<\/span><input id=\"vfb-field-1269\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" required=\"required\" type=\"hidden\" name=\"vfb-field-1269\" value=\"\"><div class=\"vfb-signature\"><\/div><div class=\"vfb-signature-buttons\"><a href=\"#\" class=\"btn btn-primary\">Reset Signature<\/a><\/div><div class=\"vfb-has-error vfb-signature-error\"><span class=\"vfb-help-block\">Signature is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1270\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1270\" class=\"vfb-control-label\">Are you ready to submit this Application?<\/label><div class=\"\"><p><span style=\"color: #ff0000;\">If you are ready to submit your application, select the &#8220;Submit&#8221; button on the bottom of this page.<\/span><\/p>\n<p><span style=\"color: #ff0000;\">Please only select the &#8220;Submit&#8221; button one time.<\/span> Once it is successfully submitted, you will see a message on the screen that the application was &#8220;successfully submitted.&#8221;<\/p>\n<p>If you have uploaded documents, it may take additional time for the Application to be submitted.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField1165\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1165\" 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=\"vfbField1166\"><button id=\"vfb-field-1166\" 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-15733","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15733","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=15733"}],"version-history":[{"count":1,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15733\/revisions"}],"predecessor-version":[{"id":15734,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/15733\/revisions\/15734"}],"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=15733"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}