CPS Demo – Missouri Credentialing Board

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CPS Exam 1 Section 1

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

List your birth date.(Required)

Month

Day

Year

Cell Phone Number(Required)

Home Phone Number

Work Phone Number

Work Extension Number

Please list Maiden Name and Other Names Used(Required)

List the county you reside in(Required)

Gender?(Required)

Ethnicity(Required)

American Indian/Native Alaskan/Native American

Asian

Black/African American

Hispanic/Lation

Multi-Racial/Ethnic

Native Hawaiian/Pacific Islander

White

Decline to State

Other

Salary(Required)

$0 - $14,999

$15,000-$24,999

$25,000-$34,999

$35,000-$44,999

$45,000-$54,999

$55,000-Over

Decline to State

Military Service(Required)

Never served in the military

Active duty for training in the Reserves or National Guard

On Active duty in the past, but not now for the Reservefs or National Guard

Now on active duty

On active duty in the past, but not now

Veteran

Primary Language(Required)

English

Spanish

Chinese

Tagalog

Vietnamese

Arabic

French

Korean

Russian

German

Other

Secondary Language(Required)

N/A

English

Spanish

Chinese

Tagalog

Vietnamese

Arabic

French

Korean

Russian

German

Other

Highest Level of Education Completed(Required)

Associates Arts/Science Degree

Bachelor Arts/Science Degree

Doctorate

High School Diploma or HiSET

No High School Diploma or HiSET

Some College Credit

Vocational Certificate

Other

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Contact MCB

428 East Capitol
3rd Floor
Jefferson City, Missouri 65101
573.616.2300
help@missouricb.com

The Missouri Department of Mental Health, Division of Behavioral Health, recognizes the Missouri Credentialing Board as the sole source
for certified peer credentials (Certified Peer Specialist, Family Support Provider, Youth Peer Specialist, and Certified Reciprocal Peer Recovery).
No other credentialing sources will be recognized as meeting the requirements for peers working in DBH certified and contracted programs.