PCS Exam Request

Please call Breining Institute at 916-987-2007, or contact us by email by selecting this link: Email

Section 1: PCS Exam Candidate Information

Full Name: *

Street Address *

Include apartment or suite number, if applicable

City *

State or Province *

ZIP Code or Country Code *

Date of Birth *

Gender *

Male

Female

Other

Prefer not to disclose

Social Security Number: Last 4 digits only *

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.

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Current Photo

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.

Section 2: Certification or License

Identify which certification or license you are testing to earn, and from which agency *

Clinical Supervisor Credential (CSC): Breining Institute

Master Counselor in Addictions (MCA): Breining Institute

Other:

If you selected Other, identify the certification and/or license and agency, here:

Section 3. Formal Education

Have you started or completed the formal education required to earn the certificate or license identified in Section 2, above? *

Yes

Not applicable

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:

Section 4: Other licenses or certifications

List any other licenses or certifications you hold in the healthcare field.

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.

License or Certificate Upload

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. If you are unable to upload the certificate or license here, please send it to us by postal mail or email.

Section 5: Credit Card and Payment Information

You give permission to and authorize Breining Institute to charge one hundred seventy-five dollars ($175.00) to the following credit card:

Includes examination, only.
Does not include retake exams (if needed).
Exam fee is nonrefundable.
Exam must be scheduled and taken within one month of submitting this exam request.
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.

Credit Card:

VISA

MasterCard

Discover

Credit Card Number:

Full Name on Credit Card:

Credit Card Expiration Date

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Link to study material, online tutorial

Questions?