{"id":20726,"date":"2021-12-30T13:44:24","date_gmt":"2021-12-30T21:44:24","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=20726"},"modified":"2021-12-30T13:46:26","modified_gmt":"2021-12-30T21:46:26","slug":"online-csc-application","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/professional-certification\/clinical-supervisor-credential-csc\/online-csc-application\/","title":{"rendered":"Online CSC Application"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-70\" 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-70\" value=\"1776350591\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"70\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">CSC Application Instructions <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2045\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2046\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2046\" class=\"vfb-control-label\"><\/label><div class=\"\"><div class=\"page\" title=\"Page 1\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<h3><span style=\"color: #008000;\">Please complete this online form carefully and completely<\/span><\/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>\u00a0In order to process your application in a timely manner, we will appreciate you providing all of the information requested.<\/li>\n<li>Please be prepared to upload a copy of a government-issued ID card and a recent passport-type photo of yourself (facing forward, no hats or sunglasses).<\/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: college@breining.edu<\/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=\"vfbField2047\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2047\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3><span style=\"color: #008000;\">Eligibility for the Clinical Supervisor Credential (CSC)<br \/>\n<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">The Clinical Supervisor Credential (CSC) is available to individuals with an underlying healthcare professional license or certification from a State-approved or recognized, or nationally-recognized, licensing or certification agency, when they meet the CSC standards and document their eligibility. <\/span><\/p>\n<p class=\"p3\"><span class=\"s1\">Within this online application, please be prepared to document the following:<\/span><\/p>\n<ul>\n<li class=\"p2\"><span class=\"s1\"><b>CURRENT CERTIFICATION OR LICENSE<\/b><\/span>\n<ul>\n<li class=\"p2\">Must hold current healthcare professional license or certification from a State-approved or recognized, or nationally-recognized, licensing or certification agency<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li class=\"p2\"><span class=\"s1\"><b>EDUCATION: 30-HOURS of ONLINE SUPERVISOR CE COURSES<br \/>\n<\/b><\/span><\/p>\n<ul>\n<li class=\"p2\">Complete any two of the specified online Clinical Supervisor Continuing Education Course Bundles (for a total of 30 hours) from Breining Institute.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li class=\"p2\"><span class=\"s1\"><b>EXPERIENCE<\/b><\/span>\n<ul>\n<li class=\"p2\"><span class=\"s1\">Three years full time or 6,000 hours clinical experience in general alcohol and other drug \/ substance use disorders (AOD\/SUD) counseling; and,<\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">One year full time (or 2,000 hours) designated as an AOD\/SUD program supervisor. <\/span><span class=\"s1\">PLEASE NOTE: Your hours as a supervisor may be included in your general AOD\/SUD experience.<\/span><\/li>\n<li><span class=\"s1\"><b>Acceptable Substitutes for Clinical Experience Requirement<\/b><\/span>\n<ul>\n<li><span class=\"s1\">The minimum clinical experience required is 2,000 hours (or 1 year)<\/span><\/li>\n<li><span class=\"s1\">An acceptable substitute for up to 4,000 hours of experience may include a degree,<\/span><span class=\"s1\"> as follows:<\/span>\n<ul class=\"ul1\">\n<li class=\"li4\"><span class=\"s1\">AA or AS degree may substitute for 2,000 hours of clinical experience;<\/span><\/li>\n<li class=\"li4\"><span class=\"s1\">BA or BS, MA or MS, or <\/span><span class=\"s1\">Doctorate degree may substitute for 4,000 hours of clinical experience<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2048\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2048\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3><span style=\"color: #008000;\">Clinical Experience Verification<\/span><\/h3>\n<ul>\n<li>Within this online application, you will let us know how many years or hours of clinical experience you have completed.<\/li>\n<li>After you have submitted this online application, you will have a qualified employer representative (or representatives) complete and submit verification of your clinical experience directly to Breining Institute, using the Breining Institute online form.<\/li>\n<li>Here is the link to the Clinical Experience Verification Form, which you may forward to your employer(s): <a href=\"https:\/\/www.breining.edu\/index.php\/1702241604-2\/clinical-experience-form\/\">Clinical Experience Verification Form<\/a><\/li>\n<\/ul>\n<\/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=\"vfbField2049\"><\/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=\"vfbField2050\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2051\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2051\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2051\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2051\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2052\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2052\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2052\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2052\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2053\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2053\" class=\"vfb-control-label\">City: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2053\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2053\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2054\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2054\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2054\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2054\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2055\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2055\" class=\"vfb-control-label\">ZIP Code or Country Code: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2055\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2055\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-select\" id=\"vfbField2056\"><label for=\"vfb-field-2056\" class=\"vfb-control-label\">Country:<\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-2056\" class=\"vfb-form-control\" placeholder=\"\" name=\"vfb-field-2056\"><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=\"vfbField2057\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2057\" class=\"vfb-control-label\">Country (if not the United States):<\/label><div><input id=\"vfb-field-2057\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2057\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2058\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2058\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2058\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-2058\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2059\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2059\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2059\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-2058\" type=\"email\" name=\"vfb-field-2059\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField2060\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2060\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2060\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-2060\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2061\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2061\" class=\"vfb-control-label\">Secondary Phone Number<\/label><div><input id=\"vfb-field-2061\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2061\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2062\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2062\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2062\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2062\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2063\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2063\" 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-2063\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2063\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2732\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2732\" class=\"vfb-control-label\">Government-issued ID Card Upload<\/label><div><span class=\"vfb-help-block\">Upload a copy of an identification card which includes your photo, in PDF or JPG format, such as a drivers license or passport or similar ID card that is issued by a government agency. This ID card will be used for our internal identification verification purposes only. If you are unable to upload a copy of your ID card here, please send it to us by email at college@breining.edu<\/span><input id=\"vfb-field-2732\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf,jpg,jpeg\" type=\"file\" name=\"vfb-field-2732\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2074\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2074\" class=\"vfb-control-label\">Current Photograph Upload<\/label><div><span class=\"vfb-help-block\">Upload a current photo of you, in PDF or JPG format, which must be no larger than 5 MB. The photo may be taken using your smart phone or similar device, and should be a passport-type photo (facing forward, no hats or sunglasses). This photo will be used on our publicly-accessible website page that verifies the award of your credential(s), and we will include it on your credential renewal certificate. In consideration of issuance of the credential referenced in this application, you expressly agree that the photo you submit and your likeness contained therein may be included in the Breining Institute \"International Credential Verification (ICV) System\" and posted on the credential verification pages of Breining Institute websites. By submitting the photo, you hereby release and discharge Breining Institute from any and all actions, claims and demands of any nature which you may have at any time now or in the future arising out of or related to the rights to the photo granted herein or your likeness.\u00a0If you are unable to upload the photo here, please send it to us by email at college@breining.edu<\/span><input id=\"vfb-field-2074\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf,jpg,jpeg\" type=\"file\" name=\"vfb-field-2074\"><\/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=\"vfbField2064\"><\/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.<\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2065\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2066\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2066\" class=\"vfb-control-label\">Email address<\/label><div class=\"\"><p>College@Breining.edu<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2067\"><label for=\"vfb-field-2067\" 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-2067-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" required=\"required\" type=\"checkbox\" name=\"vfb-field-2067[0]\" value=\"1\">30-hours of Clinical Supervisor Continuing Education Courses<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[1]\" value=\"1\">30-hours of Women's Treatment Counselor Continuing Education Courses<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[2]\" value=\"1\">30-hours of Co-occurring Disorders Continuing Education Courses<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[3]\" value=\"1\">30-hours of MAT Counselor Continuing Education Courses<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[4]\" value=\"1\">30-hours of Forensic Counselor Continuing Education Courses<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[5]\" value=\"1\">125-hours of Certified Case Manager Interventionist Training Modules<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2067-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2067\" type=\"checkbox\" name=\"vfb-field-2067[6]\" value=\"1\">I have not yet completed the required courses<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2068\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2068\" class=\"vfb-control-label\">Clinical Experience<\/label><div class=\"\"><p>Within this section, briefly describe your experience as a health care professional, including how many years or hours you have been providing services as a health care professional (you may include hours that were unpaid, such as intern hours).<br \/>\nYou will verify the hours and\/or years by having an authorized employer representative submit the Clinical Experience Verification Form, available at this link: <a href=\"https:\/\/www.breining.edu\/index.php\/1702241604-2\/clinical-experience-form\/\">Clinical Experience Verification Form<\/a><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField2069\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2069\" class=\"vfb-control-label\">Briefly describe your experience as a health care professional here: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea id=\"vfb-field-2069\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"10\" name=\"vfb-field-2069\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2070\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2070\" 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-2070\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2070\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2071\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2071\" 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.<\/span><input id=\"vfb-field-2071\" 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-2071\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2072\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2072\" 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-2072\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2072\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2073\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2073\" 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.<\/span><input id=\"vfb-field-2073\" 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-2073\"><\/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=\"vfbField2075\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2076\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2076\" 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-col-12 vfb-fieldType-instructions\" id=\"vfbField2077\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2077\" class=\"vfb-control-label\">Credit Card Charge Authorization<\/label><div class=\"\"><p>The non-refundable Application Fee for this application is $75.<br \/>\nBy submitting this online application, you are providing Breining Institute authorization to charge the Application Fee to the following credit card:<br \/>\n<span style=\"color: #ff0000;\">Please be careful to input all information carefully if you are authorizing a credit card charge now, in order to for us to promptly process your payment and application.<\/span><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField2078\"><label for=\"vfb-field-2078\" class=\"vfb-control-label\">Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2078-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2078\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2078-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2078\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2078-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2078\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField2079\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2079\" class=\"vfb-control-label\">Credit Card Number: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2079\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"number\" name=\"vfb-field-2079\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2080\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2080\" class=\"vfb-control-label\">Full Name on Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2080\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2080\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2081\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2081\" class=\"vfb-control-label\">Credit Card Expiration Date: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2081\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2081\" value=\"\"><\/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=\"vfbField2082\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2083\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2083\" 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-instructions\" id=\"vfbField2085\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2085\" 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-signature\" id=\"vfbField2084\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2084\" 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-2084\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" required=\"required\" type=\"hidden\" name=\"vfb-field-2084\" 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-captcha\" id=\"vfbField2086\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2086\" 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=\"vfbField2087\"><button id=\"vfb-field-2087\" 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":226,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-20726","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/20726","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=20726"}],"version-history":[{"count":1,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/20726\/revisions"}],"predecessor-version":[{"id":20727,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/20726\/revisions\/20727"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/226"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=20726"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}