{"id":16514,"date":"2020-06-10T12:10:05","date_gmt":"2020-06-10T19:10:05","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=16514"},"modified":"2020-06-10T12:28:44","modified_gmt":"2020-06-10T19:28:44","slug":"pcs-exam-request","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/programsservices\/pcs-exam-request\/","title":{"rendered":"PCS Exam Request"},"content":{"rendered":"\n<ul class=\"wp-block-list\"><li>Please fill out this form completely. Incomplete forms will delay processing.<\/li><li>We need a current photo to make this application complete. If you are unable to upload a current photo with this form (below), you may submit it to us by postal mail or email.<\/li><li>The $175 exam fee is non-refundable, and does not include retake exams (if needed).<\/li><li>Exam must be scheduled and taken within one month, or exam fee will be forfeited.<\/li><li>If the PCS Exam candidate does not take the exam at the scheduled exam time without at least twenty-four (24) hours advanced rescheduling of the exam, the exam fee will not be refunded, and the candidate will forfeit the exam fee, and will need to submit a new exam request and exam fee to take the exam.<\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><a href=\"http:\/\/apscal.org\/pcsexam.html\">Link to study material, online tutorial<\/a><\/h3>\n\n\n\n<h3 class=\"wp-block-heading\">Questions?<\/h3>\n\n\n\n<p>Please call Breining Institute at 916-987-2007, or contact us by email by selecting this link:&nbsp;<a href=\"http:\/\/www.breining.edu\/index.php\/contact-us\/email-us\/\" target=\"_blank\" rel=\"noreferrer noopener\">Email<\/a><\/p>\n\n\n\n<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-50\" 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-50\" value=\"1776852330\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"50\" id=\"\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 1: PCS Exam Candidate Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1366\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1367\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1367\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1367\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1367\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1406\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1406\" class=\"vfb-control-label\">Street Address <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Include apartment or suite number, if applicable<\/span><input id=\"vfb-field-1406\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1406\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1407\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1407\" class=\"vfb-control-label\">City <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1407\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1407\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1408\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1408\" class=\"vfb-control-label\">State or Province <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1408\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1408\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1409\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1409\" class=\"vfb-control-label\">ZIP Code or Country Code <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1409\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1409\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1369\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1369\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1369\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1369\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1370\"><label for=\"vfb-field-1370\" class=\"vfb-control-label\">Gender <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1370-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1370\" value=\"Male\">Male<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1370-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1370\" value=\"Female\">Female<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1370-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1370\" value=\"Other\">Other<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1370-3\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1370\" value=\"Prefer not to disclose\">Prefer not to disclose<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1371\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1371\" class=\"vfb-control-label\">Social Security Number: Last 4 digits only <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please only include the last 4 digits (numbers) of your Social Security Number. If you do not have a Social Security Number, please include the last four digits of another government identification card, and identify which government identification you are using.<\/span><input id=\"vfb-field-1371\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1371\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1372\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1372\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1372\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-1372\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1373\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1373\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1373\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-1372\" type=\"email\" name=\"vfb-field-1373\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField1374\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1374\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1374\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-1374\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField1375\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1375\" class=\"vfb-control-label\">Current Photo<\/label><div><span class=\"vfb-help-block\">We must have a current photo of the ACE Exam candidate, which will be used to verify identification of candidate at the time of the exam. You may upload it as a document with any one of the following extensions: JPG, JPEG, PNG or GIF. If you are unable to upload a photo here, please send to Breining Institute by postal mail or email attachment.<\/span><input id=\"vfb-field-1375\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" type=\"file\" name=\"vfb-field-1375\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 2: Certification or License<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1376\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1377\"><label for=\"vfb-field-1377\" class=\"vfb-control-label\">Identify which certification or license you are testing to earn, and from which agency <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1377-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1377\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1377[0]\" value=\"1\">Clinical Supervisor Credential (CSC): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1377-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1377\" type=\"checkbox\" name=\"vfb-field-1377[1]\" value=\"1\">Master Counselor in Addictions (MCA): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1377-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1377\" type=\"checkbox\" name=\"vfb-field-1377[2]\" value=\"1\">Other:<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1378\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1378\" class=\"vfb-control-label\">If you selected Other, identify the certification and\/or license and agency, here:<\/label><div><input id=\"vfb-field-1378\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1378\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 3. Formal Education<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1379\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1380\"><label for=\"vfb-field-1380\" class=\"vfb-control-label\">Have you started or completed the formal education required to earn the certificate or license identified in Section 2, above? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1380-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1380\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1380[0]\" value=\"1\">Yes<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1380-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1380\" type=\"checkbox\" name=\"vfb-field-1380[1]\" value=\"1\">No<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1380-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1380\" type=\"checkbox\" name=\"vfb-field-1380[2]\" value=\"1\">Not applicable<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1381\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1381\" class=\"vfb-control-label\">If your answer to the above is YES, please identify the course or degree that you have started or completed, and the name of the institution:<\/label><div><input id=\"vfb-field-1381\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1381\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 4: Other licenses or certifications<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1382\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1383\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1383\" class=\"vfb-control-label\">List any other licenses or certifications you hold in the healthcare field.<\/label><div><span class=\"vfb-help-block\">This will assist us in awarding the highest level RAS Credential possible. Please include a copy of your license\/certificate. This includes Registered Nurse (RN); Marriage and Family Therapist (MFT); Licensed Clinical Social Worker (LCSW); Medical Doctor (MD); and other similar licenses and\/or certifications.<\/span><textarea id=\"vfb-field-1383\" class=\"vfb-form-control\" placeholder=\"\" rows=\"10\" name=\"vfb-field-1383\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField1384\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1384\" class=\"vfb-control-label\">License or Certificate Upload<\/label><div><span class=\"vfb-help-block\">If you identified a certificate or license, above, please upload a copy of it here. You may upload it as a document with any one of the following extensions: JPG, JPEG, PNG, GIF, DOC or DOCX.\r\nIf you are unable to upload the certificate or license here, please send it to us by postal mail or email.<\/span><input id=\"vfb-field-1384\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" type=\"file\" name=\"vfb-field-1384\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 5: Credit Card and Payment Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1385\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1386\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1386\" class=\"vfb-control-label\">You give permission to and authorize Breining Institute to charge one hundred seventy-five dollars ($175.00) to the following credit card:<\/label><div class=\"\"><ul>\n<li>Includes examination, only.<\/li>\n<li>Does not include retake exams (if needed).<\/li>\n<li>Exam fee is nonrefundable.<\/li>\n<li>Exam must be scheduled and taken within one month of submitting this exam request.<\/li>\n<li>If the PCS Exam candidate does not take the exam at the scheduled exam time without at least twenty-four (24) hours advanced rescheduling of the exam, the exam fee will not be refunded, and the candidate will forfeit the exam fee, and will need to submit a new exam request and exam fee to take the exam.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1387\"><label for=\"vfb-field-1387\" class=\"vfb-control-label\">Credit Card:<\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1387-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1387\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1387-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1387\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1387-2\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1387\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField1388\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1388\" class=\"vfb-control-label\">Credit Card Number:<\/label><div><input id=\"vfb-field-1388\" class=\"vfb-form-control\" placeholder=\"\" type=\"number\" name=\"vfb-field-1388\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1389\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1389\" class=\"vfb-control-label\">Full Name on Credit Card:<\/label><div><input id=\"vfb-field-1389\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1389\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1390\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1390\" class=\"vfb-control-label\">Credit Card Expiration Date<\/label><div><input id=\"vfb-field-1390\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1390\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField1391\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1391\" 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=\"vfbField1392\"><button id=\"vfb-field-1392\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/form>\n","protected":false},"excerpt":{"rendered":"<p>Please fill out this form completely. Incomplete forms will delay processing. We need a current photo to make this application complete. If you are unable to upload a current photo with this form (below), you may submit it to us by postal mail or email. The $175 exam fee is non-refundable, and does not include [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":33,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-16514","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/16514","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=16514"}],"version-history":[{"count":3,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/16514\/revisions"}],"predecessor-version":[{"id":16520,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/16514\/revisions\/16520"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/33"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=16514"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}