Application for Certified Peer Specialist (CPS) Training 2016

Transcription

1 Application for Certified Peer Specialist (CPS) Training Program For Veterans Philadelphia, PA Dates: April 4-8 & April 11-15, 2016 Application Deadline: March 21, 2016 Cost: $ Information about the Training The Peer Specialist Certification Training is a ten day course. In order to successfully complete the Certified Peer Specialist Training Program you will need to be present and participate on all of the scheduled days. The training involves both lectures and group activities. The group activities are a place in which respect and support are very important. Qualification for certification includes successfully completing a test at the end of each week (two tests), full engagement in classroom discussions and in and out of class activities. Attendance and punctuality are also part of the assessment for certification. Trainees will receive an additional certificate of completion for the Wellness Recovery Action Plan (WRAP ), which is covered during the training for two days. Full attendance on both days is required. Taking the CPS course is no guarantee of employment. Once you have received your certificate of completion you will need to actively seek and apply for Certified Peer Specialists positions that may be available. Notification of training is based on availability of training location, having 20 participants identified and funded to attend. If you are accepted into the training program you will be contacted by the Institute for Recovery and Community Integration to confirm your attendance. Who Should Attend /Criteria The Office of Mental Health and Substance Abuse Services determine the standards for Certified Peer Specialists in Pennsylvania. For acceptance into the CPS training class offered directly by the MHASP, you must be a self-identified current or former consumer who received or are receiving state priority group services as defined in MH Bulletin OMH-94-04, Serious Mental Illness: Adult Priority Group, and who: 1. Has a high school diploma or general equivalency degree; and 2. Within the last three (3) years, has maintained at least 12 months of successful full or part-time paid or voluntary work experience or obtained at least 24 credit hours of postsecondary education. 1

2 I. CONTACT INFORMATION Full Name Please write name as you wish it to appear on your Certificate(s) of Completion. Address City State Zip Code (recommended) Phone Number (cell) Other II. Emergency Contact Information Name Address City State Zip Code (recommended): Phone Number (cell) Other Relationship to you III. DEMOGRAPHIC AND IDENTIFICATION INFORMATION Date of birth What is your race/ethnicity? (Please check all that apply to you) Asian American/Pacific Islander/East Asian Latino(a)/Hispanic African American/Black Indigenous/American Indian Caucasian/White Other racial/ethnicity descriptor Gender Identification Male Female Transgender Gender-Non-Conforming Other gender descriptor Do you have a valid Pennsylvania Driver s License? If no, do you have a valid Pennsylvania Identification Card Yes No Are you a veteran of the United States Armed Forces? If yes, dates served Branch Are you a family member of someone who has served or is currently serving in the United States Armed Forces? Have you received services from the Office of Vocational Rehabilitation within the past three years? Do you receive SSI and/or SSDI benefits? 2

3 IV. Accommodations Are there any accommodations that you need in order to participate in the training? (i.e. seeing eye dog, note taker, sign language, interpreter, etc.)? Please describe. NOTE: The Information Requested In The Next Three Sections Is Set By The Commonwealth Of Pennsylvania, Office Of Mental Health And Substance Abuse Services (OMHSAS). They Are Mandated Criteria For Training As A Certified Peer Specialist. V. EDUCATIONAL HISTORY Check all that apply and provide information about years of attendance: High School/GED Associates Degree Bachelor s Degree Master s Degree or beyond Other Education or Training Programs VI. EMPLOYMENT HISTORY If you have a current resume, please turn it in with your application. Please, list any work or volunteer experience that you have had in the past 2 years. If there is not enough space, please continue on the back of this sheet. 1. Where 2. Where 3. Where 4. Where 5. Where 3

4 VII. MENTAL HEALTH CONSUMER HISTORY*: Please select the response that reflects your lived experience. *Lived experience of Substance Use Treatment only is not sufficient to meet the requirement for CPS Training I personally identify as someone who is a present or past recipient of mental health services for a serious mental illness OR I personally identify as someone who is a present or past recipient of mental health services for a serious mental illness AND substance use challenge VIII. Please think about and answer the following questions. 1. What does recovery mean to you? What factors were important in your own recovery? 2. Please share why you are interested in peer support services and the possibility of working as a Certified Peer Specialist. 3. How does working fit in to your personal current plans? Is it something that you are interested in pursuing right now? 4. Peer specialists are models of recovery for others. In what ways do you demonstrate recovery and its goal of a full and meaningful life in the community? 4

5 5. Describe the skills you bring to the position of CPS. Also describe the skills for this work that you feel you need to develop. 6. The CPS training is an intensive two-week training course. What will be your greatest challenge in attending the CPS training and how will you address this challenge? IV. Full payment is required prior to training. Please indicate how you will be paying for the Certified Peer Specialist training. Self Office of Vocational Rehabilitation (OVR) District Send invoice to: OVR Contact Name Address Phone Sponsoring Agency or Company Send invoice to: Name Address Phone Other Send invoice to: Name Address Phone 5

6 By signing this application I am confirming that I understand, meet and agree to all of the criteria to participate in this training program. In addition, I fully intend to be present and an active participant in the Certified Peer Specialist Training Program for the entire 10 day program. Responses to all questions on the application are my own. Applicant s Signature: Thank you for your application. Sarah Perez Hernandez de Conkin Administrative Assistant Institute for Recovery & Community Integration 1211 Chestnut Street, 10 th floor Philadelphia, PA Phone: sperezhernandez@mhasp.org Fax: Please submit any questions and your completed application to: Please be sure to include the following: Completed Application (REQUIRED): Fully answer every question asked on this application. Recommendation Letter (REQUIRED): Please provide at least one letter of recommendation from someone who knows your potential as a peer supporter. Ask the person to indicate their relationship to you and how they know you in the letter. Recommendation letters may be written by former or present employers, teachers, volunteer supervisors, clergy, or staff who has provided services or treatment with you. Payment (REQUIRED): Full payment is required prior to training. Kindly remember to completely fill out section IV with information about payment. An invoice will be sent once accepted into the training. Signature (REQUIRED): Remember to sign the application Current Resume (Optional) Cancellation/refund policy: Refund requests received 30 days or more prior to the course start date will be honored. Refund requests made less than 30 days prior to the course start date will incur a $50 processing fee. No refunds will be made on or after the course start date 6