Professional Credential Application Form

Credential *

Please complete this online form carefully and completely

In order to process your application in a timely manner, we will appreciate you providing all of the information requested.
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:
- Email: college@breining.edu

Which internationally-awarded Breining Institute credential are you seeking?

Applicant Information *

Section 1. Applicant Information

Full Name: *

Address: *

City: *

State / Province: *

ZIP Code or Country Code: *

Country:

Country (if not the United States):

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Secondary Phone Number

Date of Birth *

Social Security Number *

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.

Documentation *

Documentation

In this section, please provide information about your qualifications for the credential you are seeking. You 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:

Email address

Administration@Breining.edu

Mailing Address

Breining Institute – Admissions Office, 8894 Greenback Lane, Orangevale, California 95662-4019

Facsimile Number

916-987-8823

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.

Specialty Course Completion *

Please select the Breining Institute specialty course you have completed which is a requirement for the credential you are seeking.

40-hour Clinical Supervisor Education Course

40-hour Women's Treatment Counselor Education Course

40-hour Co-occurring Disorders Education Course

40-hour MAT Counselor Education Course

40-hour Forensic Counselor Education Course

125-hour Certified Case Manager Interventionist Training Modules

I have not yet completed the required course

Clinical Experience

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.

Professional Reference

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.

Degree Verification

If applicable, list your degree(s) here, and then upload or send us a copy of your diploma or transcripts.

Degree Upload

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.

Current License or Certification

If applicable, list your relevant license(s) or certification(s) here, and then upload or send us a copy of them.

License or Certification Upload

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.

Current Photograph Upload

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.

Application Submission *

By submitting this Application, you agree to comply with this Code of Ethics:

As a an alcohol and other drug / substance use disorders (AOD/SUD) professional, I will comply with this Code of Ethics and do affirm:

That my primary goal is recovery for the client and the client’s family, through conducting my role  as a counselor and/or supervisor in a professional and caring manner.
That I have a total commitment to provide the highest quality of supervision to those whom I am  committed to providing supervision. That I shall not provide services beyond the terms and  conditions of my professional certifications and/or licenses.
That I shall evidence a genuine interest in all of the individuals that are counseled and/or supervised by me, and do  hereby dedicate myself to the best interest of my agency and clients, and to help them help  themselves.
That I shall maintain at all times an objective, professional relationship with all of my clients.
That I shall adhere to the Rule of Confidentiality with regard to all records, material and knowledge  concerning my client, and shall protect his/her rights to confidentiality in accord with Code of  Federal Regulations, Title 42 sections 2.1 through 2.67(1) and any other applicable regulations.
That I shall cooperate with complaint investigation and supply information requested during such  complaint investigations, subject to the confidentiality provisions cited above.
That I shall not in any way discriminate between clients or fellow professionals on the basis of race,  religion, age, gender, disability, national ancestry, sexual orientation or economic condition.
That I shall respect the rights and views of my fellow counselors and other addiction professionals.  I will not verbally, physically or sexually harass, threaten, or abuse any program participant, patient,  client or fellow addiction professional.
That I shall maintain respect for institutional policies and management within agencies, and will  take the initiative toward improvement of such policies and management when it will better serve  the interests of my clients.
That I have a continuing commitment to assess my own personal strengths, limitations, biases and  effectiveness.
That I shall continuously strive for self-improvement and professional growth through further  education and training.
That I have an individual responsibility for my own conduct in all areas, including, but not limited to,  the 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).
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.
These things I pledge to my professional peers and to my clients.
I hereby pledge to comply with this Code of Ethics, as well as to comply with a consistent code of  conduct that may be applicable to a recovery or treatment program with which I may be affiliated.

Attestation

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.

Signature *

Please carefully use this space to sign your name.

Reset Signature

Signature is required.

Are you ready to submit this Application?

If you are ready to submit your application, select the “Submit” button on the bottom of this page.

Please only select the “Submit” button one time. Once it is successfully submitted, you will see a message on the screen that the application was “successfully submitted.”

If you have uploaded documents, it may take additional time for the Application to be submitted.

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