© 2014 Breining Institute – www.breining.edu (1409040627) RAS to CATC TRANSITION / RENEWAL 1

CALIFORNIA COUNSELORS: Registration and Certification Renewal

Breining Institute • 8894 Greenback Lane • Orangevale, California USA 95662-4019 • Telephone (916) 987-2007

CALIFORNIA COUNSELORS: Breining Institute is transitioning all California counselors to CAADE. Your California AOD counselor registration (to stay in compliance with California law) will be renewed with CAADE. Your RAS Credential will be renewed with a CATC Credential, and Breining will also renew your RAS Credential.

When you renew through Breining, we will also renew all of your Breining Advanced and Specialty Credentials at no extra cost.

SECTION 1: CREDENTIAL HOLDER Name ____________________________________________________________________________________________ Address ____________________________________________________________________________________________ City ____________________________________________________________________________________________ State _________________________________________ ZIP Code ______________________________ E-mail _________________________________________ Phone ______________________________ SECTION 2: CURRENT BREINING CREDENTIALS ☐ Registered Addiction Specialist INTERN (RASi) ☐ Clinical Supervisor Credential (CSC) ☐ Registered Addiction Specialist (RAS) ☐ Master Counselor in Addictions (MCA) ☐ RAS – Level II (RAS II) ☐ Certified Women’s Treatment Specialist (CWTS) ☐ RAS – Level III (RAS III) ☐ Medication-Assisted Treatment Counselor (MATC) ☐ Masters Level – RAS (M-RAS) ☐ Forensic Addiction Counselor (FAC) ☐ Certified Co-occurring Disorders Specialist (CCDS) SECTION 3: ATTESTATION OF CONTINUING EDUCATION COMPLETION I attest that I have or will complete the required CE courses for the applicable certification(s) by my current renewal date: ☐ RAS, RAS II, RAS III, or M-RAS: 40 hours in general AOD/SUD topics, including 10 hours in Ethics ☐ CSC: 40 hours in general AOD/SUD topics, which includes 6 hours in Clinical Supervision topics ☐ MCA: 40 hours in general AOD/SUD topics, including 10 hours in Ethics ☐ MATC, FAC, CWTS or CCDS: Must maintain underlying certification, plus 6 hours in specialty topics SECTION 4: ATTESTATION OF ADHERENCE TO CODES OF ETHICS / CONDUCT, SCOPE OF PRACTICE I attest that I will adhere to the applicable Code of Ethics, Code of Conduct and Scope of Practice, including: • California AOD Counselor Uniform Code of Conduct (http://breining.edu/CUCCMar312012Final.pdf) • CAADE Code of Ethics (http://caade.org/sites/default/files/CAADE_Ethics_July29-11.pdf) • CAADE Scope of Practice (http://caade.org/sites/default/files/Scope%20of%20Practice.pdf)

SECTION 5: PAYMENT INFORMATION (Select only one) ☐ 2-year California registration with CAADE renewal only (for non-certificate holders) .................................................... $ 75.00 ☐ 2-year RAS renewal / transition to CATC (includes CAADE registration to satisfy California registration law) ............. $150.00

• Includes renewal of all Breining issued credentials, including RAS. • Late renewal fee (if applicable) is waived for this renewal.

Checks for this renewal / transition should be made payable to “Breining Institute.” If paying by VISA, MasterCard or Discover, you may fax, e-mail or send by postal mail this form to: • FAX number: 916-987-8823 • E-mail: Certification@Breining.edu • Mailing address: Breining Institute, 8894 Greenback Lane, Orangevale, California USA 95662-4019

• Credit card number: _______________________________________________________________

• Full name on credit card: _______________________________________________________________

• Credit card expiration date: _______________________________________________________________