{"id":23422,"date":"2022-06-15T08:31:35","date_gmt":"2022-06-15T15:31:35","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=23422"},"modified":"2022-06-15T09:25:22","modified_gmt":"2022-06-15T16:25:22","slug":"student-info-15-hr-clinical-supervisor-course-part-three","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/professional-certification\/clinical-supervisor-credential-csc\/student-info-15-hr-clinical-supervisor-course-part-three\/","title":{"rendered":"STUDENT INFO: 15-hr Clinical Supervisor Course &#8211; Part THREE"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-92\" 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-92\" value=\"1777542053\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"92\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Student Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2871\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2845\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2845\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3 class=\"has-very-dark-gray-color has-text-color has-vivid-red-color\"><span style=\"color: #008000;\"><strong>3 easy steps:<\/strong><\/span><\/h3>\n<ol>\n<li>\n<h4>Complete the <span style=\"color: #008000;\">STUDENT INFORMATION<\/span>, below.<\/h4>\n<\/li>\n<li>\n<h4>Use the PayPal processing page to make your <span style=\"color: #008000;\">PAYMENT<\/span> for the course (you do not need a PayPal account).<\/h4>\n<\/li>\n<li>\n<h4>Complete the <span style=\"color: #008000;\">ANSWER SHEET<\/span>, and you will then be automatically provided a CE Completion Certificate, and one will also be emailed to you.<\/h4>\n<\/li>\n<\/ol>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><span class=\"vfb-help-block\"><h3><span style=\"color: #008000;\">STUDENT INFORMATION<\/span><\/h3><\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2846\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2847\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2847\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2847\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2847\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2848\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2848\" class=\"vfb-control-label\">Street Address <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2848\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2848\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2849\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2849\" class=\"vfb-control-label\">City <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2849\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2849\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2850\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2850\" class=\"vfb-control-label\">State or Province <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2850\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2850\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2851\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2851\" class=\"vfb-control-label\">ZIP Code (or Postal Code) <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2851\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2851\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2852\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2852\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please carefully enter your email address, which we will use to send you the Completion Certificate.<\/span><input id=\"vfb-field-2852\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-2852\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2853\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2853\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2853\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-2852\" type=\"email\" name=\"vfb-field-2853\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2854\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2854\" class=\"vfb-control-label\">Do you hold professional healthcare and\/or counseling Licenses \/ Certifications?<\/label><div><span class=\"vfb-help-block\">If applicable, please identify professional healthcare license(s) and\/or certification(s) that you currently hold, and include the name(s) of the agency or agencies.\r\n<\/span><input id=\"vfb-field-2854\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2854\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2855\"><label for=\"vfb-field-2855\" class=\"vfb-control-label\">Do you hold internationally-awarded Breining Institute credentials?<\/label><div><span class=\"vfb-help-block\">If you have earned one or more internationally-awarded credentials from Breining Institute, please select which ones below (select all that apply):<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[0]\" value=\"1\">Registered Addiction Specialist (RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[1]\" value=\"1\">Advanced RAS - Level II (RAS II)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[2]\" value=\"1\">Advanced RAS - Level III (RAS III)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[3]\" value=\"1\">Masters Level - RAS (M-RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[4]\" value=\"1\">Clinical Supervisor Credential (CSC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[5]\" value=\"1\">Master Counselor in Addictions (MCA)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[6]\" value=\"1\">Certified Women's Treatment Specialist (CWTS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[7]\" value=\"1\">Medication-Assisted Treatment Counselor (MATC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[8]\" value=\"1\">Forensic Addictions Counselor (FAC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[9]\" value=\"1\">Certified Co-occurring Disorders Specialist (CCDS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[10]\" value=\"1\">Certified Case Manager Interventionist - Associate Level (CCMI-A)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[11]\" value=\"1\">Certified Case Manager Interventionist (CCMI)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2855-12\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2855\" type=\"checkbox\" name=\"vfb-field-2855[12]\" value=\"1\">Certified Case Manager Interventionist - Masters Level (CCMI-M)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2856\"><label for=\"vfb-field-2856\" class=\"vfb-control-label\">How did you find out about this course? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2856-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2856\" required=\"required\" type=\"checkbox\" name=\"vfb-field-2856[0]\" value=\"1\">Friend, colleague or co-worker<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2856-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2856\" type=\"checkbox\" name=\"vfb-field-2856[1]\" value=\"1\">Social media (such as Facebook, LinkedIn)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2856-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2856\" type=\"checkbox\" name=\"vfb-field-2856[2]\" value=\"1\">Program Supervisor or Manager<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2856-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2856\" type=\"checkbox\" name=\"vfb-field-2856[3]\" value=\"1\">Licensing or Certification agency<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2856-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2856\" type=\"checkbox\" name=\"vfb-field-2856[4]\" value=\"1\">Other<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField2857\"><label for=\"vfb-field-2857\" class=\"vfb-control-label\">Years in AOD\/SUD and\/or Healthcare Profession <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">How long have you been providing professional AOD\/SUD counseling services, or have been in the healthcare profession?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"Less than 1 year\">Less than 1 year<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"1 - 3 years\">1 - 3 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"3 - 5 years\">3 - 5 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-3\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"5 - 10 years\">5 - 10 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-4\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"10 - 15 years\">10 - 15 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-5\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"15 - 20 years\">15 - 20 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2857-6\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2857\" value=\"More than 20 years\">More than 20 years<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Payment Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2872\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2858\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2858\" class=\"vfb-control-label\">CE Course Payment<\/label><div class=\"\"><h4><span style=\"color: #ff0000;\">The Completion Certificate Fee for this course is $59.<\/span><\/h4>\n<h4>When you select the \u201cSubmit\u201d button below, you will be directed to a payment page where you can charge the fee to a credit card or to a PayPal account.<\/h4>\n<h4>After you submit your payment information, please allow PayPal a few seconds to process the payment, <span style=\"color: #000000;\">and you will then have 60 minutes to complete the exam.<\/span><\/h4>\n<h4>Select the \u201cSubmit\u201d button below <span style=\"color: #ff0000;\">when you are ready to pay and complete the exam<\/span> for the Course Completion Certificate.<\/h4>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField2859\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2859\" 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=\"vfbField2860\"><button id=\"vfb-field-2860\" 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-23422","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/23422","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=23422"}],"version-history":[{"count":2,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/23422\/revisions"}],"predecessor-version":[{"id":23425,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/23422\/revisions\/23425"}],"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=23422"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}