HRS Renweal – Harm Reduction Specialist

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Date

Name*

First Middle Last

Address*

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

Your Home Phone Number:

Please list a number where we may contact you.

Your Cell Phone Number:*

Please list a number where we may contact you.

Your Work Phone Number:

Please list a number where we may contact you.

Place of Employment:*

Address of Employer:*

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

Your Email Address:*

Your email address listed above will be used by staff to correspond with you if there is a problem with your renewal materials when they are reviewed. Check your SPAM folder for email from staff.

Within the last renewal period have you been charged, found guilty, or entered a pleas of nolo contendere, in a criminal prosecution under the laws of any state or the United States for any offense, whether or not sentence was imposed or executed?*

Yes

If yes, please upload a written explanation.

Upload your written explanation here*

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Accepted file types: gif, png, pdf, doc, xls, xlsx, docx, pptx, ppt, bmp, jpeg, jpg, Max. file size: 5 MB, Max. files: 1.

List Other Professional Counseling Credentials You Hold*

Demographics

Gender*

Female

Male

Decline to state

Other

Ethnicity:*

American Indian/Native Alaskan/Native American

Asian

Black/African American

Decline to state

Hispanic/Latino

Multi-Racial/Ethnic

Native Hawaiian/Pacific Islander

White

Other

Salary:*

$0-$14,999

$15,000-$24,999

$25,000-$34,999

$35,000-$44,999

$45,000-$54,999

$55,000-Over

Native Hawaiian/Pacific Islander

Decline to State

Military Service:*

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 Reserves or National Guard

Now on active duty

On active duty in the past, but not now

Veteran

Primary Language:*

Secondary Language:*

Highest Level of Education Completed:*

Associates Arts/Science Degree

Bachelor Arts/Science Degree

Master’s Degree

Doctorate

High School Diploma or HiSET

Some College Credit

No High School Diploma or HiSET

Vocational Certificate

Other

Credential Renewal

Please mark all credentials you are renewing at this time:*

HRS Active - $77

HRS Inactive - $38.50

Write the credential number for the HRS you are renewing at this time.*

Write the credential number for the HRS you are making inactive at this time.*

Renewal Application—Attestation Statement

To complete the renewal you must sign and upload page 5 of the renewal packet here.

Upload your Renewal Application—Attestation Statement here.*

Page 5 of the Renewal Packet.

Drop files here or

Accepted file types: gif, png, pdf, doc, xls, xlsx, docx, pptx, ppt, bmp, jpeg, jpg, Max. file size: 5 MB, Max. files: 2.

Signature Page for Code of Conduct and Authorization and Release

To complete the renewal you must upload a signed copy of page 6 of the renewal packet here.

Upload Signature Page for Code of Conduct and Authorization and Release Here*

Page 6 of the Renewal Packet.

Drop files here or

Accepted file types: gif, png, pdf, doc, xls, xlsx, docx, pptx, ppt, bmp, jpeg, jpg, Max. file size: 5 MB, Max. files: 2.

Upload Your Forms

All renewals MUST submit a copy of their Ethics Training

Upload your forms and training certificates here.*

Please upload your 20 HRS renewal hours—6 hours of ethics and 8 hours of harm reduction hours
YOU MUST SUBMIT ALL CERTIFICATES—NOT JUST ETHICS HOURS. No credential will be renewed until all documents are submitted.

Drop files here or

Accepted file types: gif, png, pdf, doc, xls, xlsx, docx, pptx, ppt, bmp, jpeg, jpg, Max. file size: 10 MB, Max. files: 20.

Renewal Fees

Renewal materials postmarked on or before July 31, 2025

Please mark all credentials you are renewing at this time*

HRS Active $100

HRS Inactive $50

Payment

Subtotal

$0.00

A 3.5% service charged will be applied to all payments made by credit card.*

Price: $0.00

Total

Credit Card

Card Details

Cardholder Name

IC & RC HRS Renewal

IC & RC 2025 RENEWAL FORM

Demographics

Credential Renewal

Renewal Application—Attestation Statement

Signature Page for Code of Conduct and Authorization and Release

Upload Your Forms

Renewal Fees

Payment

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