Certified Peer Specialist Training Application

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1 Please read the CPS Application Supplement before completing application. Go to This training is intended for individuals who will use their lived experience with mental health recovery in a peer support role. It is not intended for people who work exclusively in clinical or administrative positions. If you are a Veteran working with other Veterans, please note that we will be holding a Veterans specific training on August 15-19th and we encourage you to apply to that training instead. Please refer to our website for details on that training as they are confirmed. Training Dates: July 24-30, 2016 Training Location: Austin, TX Application and Registration Fees The registration for Certified Peer Specialist training is $750. (The full cost to Via Hope to provide the training is approximately $1,000.) The registration fee covers all class supplies and materials plus breakfast/lunch, and hotel accommodations (for those traveling over 30 miles to the training) for each day of the training. If accepted for training an invoice will be sent via to the applicant or the applicant s employer, and payment must be received no later than July 20th. If the applicant is unable to attend for a valid reason and notifies Via Hope at least three business days prior to the training, a full refund will be provided. Candidates selected to participate in this training are responsible for arranging and paying for their own travel to and from the training, their evening meals, and any other incidental expenses. If you do not have an employer to cover the registration, travel, and meal costs, and the additional expense would prevent you from attending the training, you may apply for a scholarship. Once accepted to the training, scholarship assistance must be requested by the deadline mentioned in the acceptance letter and is not guaranteed. The scholarship payment may not be received prior to the start of the training. Scholarships are limited and granted based on availability of funds and proof of financial hardship. Training Eligibility Requirements Individuals must be age 18 or older. Individuals must be a high school graduate or have completed a G.E.D. Individuals must have lived experience in mental health recovery, current or prior use of mental health services, and a desire to use her/his experiences to help others with their recovery. Individuals must be willing to publicly identify as a person with lived experience in order to model the reality of recovery. Via Hope actively welcomes a diverse group of training applicants with respect to race, color, ethnicity, gender, age, sexual orientation, and lived experience. Our Mission: We provide education, training, and consultation to empower individuals, families, and youth to develop resilience, achieve recovery, and further mental health system transformation South Lamar Blvd., Unit E-102 Austin, TX or

2 Application, Selection, and Participation Requirements The application must be completed in its entirety. Two letters of recommendation must be submitted with the application. Enrollment is limited; priority is given to applicants currently employed or volunteering in a peer position. Selection is based primarily on information provided in this application. However, a telephone interview may also be conducted. Completing the application does not guarantee acceptance to the training. Applicants must agree to attend and actively participate in five full days of training. If approval for attendance must be obtained from an employer, authorization must be completed prior to submitting application. Attendees will participate in discussion and role-plays utilizing personal experiences as individuals in recovery, rather than clinical roles or training. Graduates must pass a written exam given the day after the final day of the training to become certified. Complete the following pages. completed application to: or Fax pages 3-8 to: or Mail pages 3-8 to Via Hope 4604 South Lamar Blvd., Unit E-102 Austin, TX Applications are due by Friday, June 10, 2016 Applicants will receive a notification of receipt via within 48 hours of submission. If you do not receive this , please call us at to follow up. Applicants will be notified on Friday, June 24th (by 5PM) whether they are accepted. Registration Fees must be received by Wednesday, July 20, Our Mission: We provide education, training, and consultation to empower individuals, families, and youth to develop resilience, achieve recovery, and further mental health system transformation South Lamar Blvd., Unit E-102 Austin, TX or

3 Certified Peer Specialist Training, July 24-30, 2016, Austin, TX Answer the following questions to the best of your ability. You may type in your answers and save this form, or you may print the blank form and hand write your answers. Answer all questions on the sheets provided. This is not a test. There are no right or wrong answers, but you must answer all questions and sign your application. Contact Information Last Name: First Name: M.I. Home Address: City: State: TX Zip: Address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - You must initial that all of the following apply to you: Candidate Eligibility Checklist I have read the application supplement. I am 18 years or older. I have a High School Diploma or GED. I myself completed this application. I identify myself as a person who has personal lived experience with mental health recovery. I have lived experience with mental health recovery or a co-occurring disorder, rather than a substance use diagnosis. I have significant experience working on my recovery and I am able to manage my own wellness. I agree to disclose my personal lived experience as it relates to mental health for the purpose of educating, role modeling and providing hope to others about the reality of recovery. Recovery Experience 1. Do you currently hold a peer support position and expect to do the work of a Certified Peer Specialist following this training? Yes No This position is (check one): Paid or Volunteer How long have you had this position? Years Months If paid position, rate: $ per. Average # of hours per week you work or volunteer in this position: Name/Address of Employer: Supervisor Name/Title: Supervisor Phone ( ) - My Job Title: My responsibilities include:

4 2. If no to # 1, have you been offered a position working as a peer specialist? Yes No NA This position is (check one): Paid or Volunteer If yes, when will you start? Month/day Year Average # of hours per week you will work or volunteer in this position: Name/Address of Employer: Supervisor Name/Title: Supervisor Phone ( ) - My responsibilities will include: 3. If not currently employed, have you had prior experience as a peer specialist? Yes No NA If yes, Name/Address of Employer: Dates of employment: Month Year to Month Year. Hours worked per week: 4. If not currently employed, are you actively seeking work as a peer specialist? Yes No NA 5. What does recovery mean to you personally? 6. What is your concept of the role of a Certified Peer Specialist (CPS)? 7. Why do you want to work as a Certified Peer Specialist?

5 8. Have you developed a personal WRAP? Yes No If yes, when? Month Year 9. Have you had training as a WRAP facilitator? Yes No If yes, when? Month Year 10. What things do you do to maintain your wellness? 11. What personal qualities do you possess that make you effective in working with other people in recovery? 12. What factors or people were/are important and helpful in your own recovery? 13. What prior peer recovery related training have you had (e.g. Intentional Peer Support, NAMI Peer to Peer, Focus for Life, etc.)? 14. Have you applied to Via Hope s Certified Peer Specialist Training in the past? Yes No If yes, when? Month Year 15. What specific experiences have you had in assisting people in their recovery (i.e. leading support groups, self-advocacy, program involvement, public testimony, etc.)? Did this include sharing your recovery story?

6 16. Certified Peer Specialist Skills Assessment Check Yes or No to each statement below. You may be asked to give a detailed explanation of your answers during a phone interview. 1. Are you comfortable disclosing to clients, staff, and the general public that you have lived experience with mental health recovery? 2. Can you describe what you have had to overcome to get to where you are today in your recovery? 3. Can you describe what has helped you move from where you were to where you are now? What did you do for yourself, and what did others do to help? 4. Can you describe what you have learned about yourself in your recovery, and what strengths you have? 5. Can you describe some of the things that you do daily to maintain your wellness? Yes No 6. Can you describe some of the things you have found helpful in combating negative selftalk? 7. Do you believe that you could help someone understand recovery and try to convince someone who did not believe in recovery that it is possible? 8. Can you describe the role that a sense of hope and resilience played in your life and your recovery? 9. Can you describe some of the community supports you have and how they were useful in your recovery? 10. Have you ever led a group? Did you enjoy it? What did you like about it? 17. Are you fluent in any other language(s) besides English? If so, which ones? Verbal Written 18. Do you have a food allergy or require a special diet (i.e.: Vegetarian, Gluten-free, etc.)? If so, please describe below.

7 Participation Requirements Checklist You must initial that you agree to all of the following: I will attend and actively participate in the full five days of training and will not miss more than 4 hours of the training. I will participate in discussion and role-plays utilizing my personal experiences and sharing my recovery story. I understand that I am not guaranteed employment or a volunteer position as a result of participating in this training. I agree to take the written certification exam given the morning after the training. The exam consists of 70 multiple choice questions written in English. Are there reasonable accommodations for a disability needed (either for the training or the written certification exam)? Yes No If yes, please describe: Please sign below if you have read and understand what is expected of all applicants, and to verify all information you provided is correct. Your application will not be considered if not signed and filled out completely. Signed or Printed Name Optional Demographic Information (Used by Via Hope to measure diversity in the peer workforce.) Gender Age Group Male Female Race/Ethnicity (Check all that apply) Do you consider yourself of Latino or Hispanic origin? Yes No What is your race/ethnicity? (Check all that apply): African American White Asian or Pacific Islander Indian/Native American Other

8 Applications must be received no later than Friday, June 10, completed application to: OR Fax completed application to: OR Mail completed application to: Via Hope 4604 South Lamar Blvd., Unit E-102 Austin, TX Candidates will be notified of acceptance into the class on June 24, 2016 (by 5PM). Registration Fees must be received by Wednesday, July 20, 2016.

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