CPCS Inactivation Request

First Name *

Last Name *

Email *

CPCS # *

I am yielding my CPCS Clinical Supervision credential based one of the following: *

I am no longer providing supervision.

I am providing supervision, but I am an Approved Clinical Supervisor (ACS) with CCE/NBCC.

I hereby agree that I am yielding my CPCS Credential and will discontinue using the CPCS credential on ALL communications, marketing materials, website listings, etc.

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