Online CCDS Application – Breining Institute

CCDS Application Instructions *

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.
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).
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

Eligibility for the Certified Co-occurring Disorders Specialist (CCDS) Credential

The Certified Co-occurring Disorders Specialist (CCDS) Credential 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 CCDS standards and document their eligibility.

Within this online application, please be prepared to document the following:

CURRENT CERTIFICATION OR LICENSE
- Must hold current healthcare professional license or certification from a State-approved or recognized, or nationally-recognized, licensing or certification agency

EDUCATION: 30-HOURS of ONLINE CCDS CONTINUING EDUCATION COURSES
- Completion of any two of the online Certified Co-occurring Disorders Continuing Education Course Bundles (for a total of 30 hours) from Breining Institute

EXPERIENCE
- Three years full time or 6,000 hours clinical experience in general alcohol and other drug / substance use disorders (AOD/SUD) counseling.
- Acceptable Substitutes for Clinical Experience Requirement
  - The minimum clinical experience required is 2,000 hours (or 1 year)
  - An acceptable substitute for up to 4,000 hours of experience may include a degree, as follows:
    - AA or AS degree may substitute for 2,000 hours of clinical experience;
    - BA or BS, MA or MS, or Doctorate degree may substitute for 4,000 hours of clinical experience

Clinical Experience Verification

Within this online application, you will let us know how many years or hours of clinical experience you have completed.
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.
Here is the link to the Clinical Experience Verification Form, which you may forward to your employer(s): Clinical Experience Verification Form

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.

Government-issued ID Card Upload

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

Current Photograph Upload

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. If you are unable to upload the photo here, please send it to us by email at college@breining.edu

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.

Email address

College@Breining.edu

Specialty Course Completion *

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

30-hours of CD Counselor Continuing Education Courses

I have not yet completed the required courses

Clinical Experience

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).
You will verify the hours and/or years by having an authorized employer representative submit the Clinical Experience Verification Form.

Briefly describe your experience as a health care professional here:

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.

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.

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.

Credit Card Charge Authorization

The non-refundable Application Fee for this application is $75.
After you select the “Submit” 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.

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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