1 of 5 PART I. TIMETABLE FOR APPLICATION PROCESS Thank you for your interest in PRS the Volunteer opportunity with Living Proof Outreach. This volunteer opportunity with assist you in gaining the 500hrs needed to become certified through Virginia Certification Board. The candidate will be supervised by the director of LPO and will have several opportunity to provide peer support, through groups, one on one, as well as community outreach. This application has 6 parts. All parts must be completed in order for your application to be considered. In part V, please answer all questions on a separate sheet of paper. Once your application is reviewed, you will be called for a required personal interview. Mail applications to: Calendria Jones 7750 Stand Circle Apt 401 Mechanicsville, VA 23111 I Prefer EMAIL E-mail applications to: calen2jones@gmail.com *Please note: If emailing application, you MUST be sure page 3 is signed before emailing*.
PART II. PERSONAL INFORMATION: PLEASE TYPE OR PRINT CLEARLY 2 of 5 Last Name: First Name: Home Phone: Home Address: Cell Phone: ( ) Home Email: Please print your name as you want it on your certificate: City/County in which you work /volunteer/or receive services: Current status: (Check all that apply): I work here. I volunteer here. Other Employer: Current job title: Work Phone: ( ) Work Email: Work address: Volunteer organization (if different than work): High School Grad/GED Some College College Graduate Post Graduate Education Recovery related Trainings e.g. WRAP, CELT, NAMI Peer to Peer. (Please include date of completion) Specify (If you wish, attach a separate sheet with additional work or volunteer experience or certifications.) Ethnicity - I am (check one optional) African American Asian Caucasian American Indian/Alaskan Native Multiracial Other (please specify) Hispanic Non Hispanic I have been told by an organization or agency that I will be hired as a Peer Support Specialist once I complete this course. Name of above organization:
PART III. UNDERSTANDINGS: INITIAL ONLY THOSE THAT APPLY I understand that Peer Specialists work from the perspective of their lived experience with mental illness & substance recovery. I agree to be open about the fact that I have been diagnosed with a mental health challenges or substance recovery. I understand that in doing so I help educate others about the reality of recovery. 3 of 5 I have lived experience in recovery from a mental health challenges and/or substance use challenges.. I openly identify and agree to openly disclose my recovery process. I am in active recovery and am using a recovery plan (such as 12 Steps or WRAP). I will participate fully in this volunteer opportunity, attend all the trainings suggested by LPO. I understand weekly one on one with LPO director is mandatory for this volunteer opportunity. I understand that I am responsible to make all my own travel arrangements to outreach sites. I understand that this Peer Recovery Specialist volunteer opportunity, is not a job placement program and that no guarantee of job placement is included as part of this volunteer experience. PART IV. SIGNATURE I certify that I have given true, accurate, and complete information on this form to the best of my knowledge and willing participating in this volunteer opportunity with LPO. Your signature: Date: Please also print your name:
4 of 5 PART V. ESSAY QUESTIONS: COMPLETE ON A SEPARATE PIECE OF PAPER Answer all questions on your own. Your answers can be brief but please use complete sentences. This is not about right & wrong answers. It is to assess your understanding of the requirements to be a participant in this Peer Specialist training and your lived experience with recovery. Peer Specialists assist individuals they serve in many activities requiring these skills. 1. What difference do you anticipate in your life as a result of participating in Peer Recovery Specialist Training? 2. What types of experiences have you had in advocating for consumers of mental health services? Please describe in detail, listing efforts in letter-writing, personal advocacy, public testimony, programs you began, or the work you are doing now. Be specific. 3. How long have you been in recovery? 4. How do you maintain your recovery? 5. What skills and resources do you use in your recovery? 6. What does recovery mean to you? 7. Is there anything else you would like us to know in considering you for the Peer Specialist Training? PART VI. PERSONAL REFERENCES Include two (2) References - See next page for form.
PART VI. PERSONAL REFERENCE FORM I am applying for LPO Peer Specialist Volunteer position. Complete this form email or scan to the email below. E-mail reference to: calen2jones@gmail.com Fax to: 804-503-6489 Mail reference to: Calendria Jones (CPRS) 7750 Stand Circle apt 401 Mechaniscville, VA 23111 5 of 5 Name of Applicant 1. Please describe your relationship with the applicant. 2. Please describe your experience with the applicant that indicates his/her demonstrated recovery. 3. Please describe strengths or assets this applicant will offer as a Peer Support Specialist. Signature (email signature acceptable) Date Contact Information (Please Print) Name: Phone: Email: Address: ( )