CONTACT AND DEMOGRAPHIC INFORMATION (**Optional. For statistical purposes only) **Race Preferred Name **Are you a US military veteran?

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1 Core Training Program Application Application must be legible, fully completed and received no later than the deadline noted on the website or announcement. In order to be considered for possible admission into Core Training, you must be a NJ consumer of mental health or co-occurring services. Co-occurring is defined as having a mental health diagnosis and a substance use disorder. In order to be eligible for admission into this program, you must meet the following criteria: A New Jersey State resident A desire to work in the mental health and or co-occurring field as a peer Able to benefit from a classroom learning environment Have belief and practice in personal recovery Must have two years sobriety if you have a co-occurring disorder CONTACT AND DEMOGRAPHIC INFORMATION (**Optional. For statistical purposes only) Legal Name (Last, First) **Nationality/Ethnicity **Race Preferred Name **Are you a US military veteran? Yes No **Gender: Male Female /County **Date of Birth Phone Number (home) Emergency Contact Name/Number Phone Number (cell) Are you a NJ Resident? Yes No ELIGIBILITY CRITERIA Are you currently a consumer of mental health and/or co-occurring How many years of continuous recovery have you had? treatment services? Yes No Where do you receive services? Name of organization (s) Describe in your own words what Recovery means. What is your definition of a Peer Specialist? 1

2 ELIGIBILITY CRITERIA Do you identify yourself as a consumer? Yes No Have you participated in any WRAP training? Yes No If yes, year and name of organization Do you have a WRAP plan (Wellness Recovery Action Plan)? Yes No Have you been hospitalized or treated for crisis intervention for your mental health or co-occurring diagnosis? Yes No Do you have natural supports? i.e. family, peer(s), community based, self help center, etc. Yes No If yes, what year? State hospital County hospital Private hospital Respite Home Crisis Center Early Intervention Support Services TRANSPORTATION Do you have a valid NJ Driver s License? Yes No Do you rely on public transportation? Yes No If yes, do you have access to a vehicle? Yes No If no, what is your means of transportation? Do you have points on your driving record? Yes No If yes, how many? How far would you commute to work? miles How far would you commute to Core Training? miles What is your highest level of education? Graduate College Undergraduate College Business/Trade High School GED EDUCATION/EMPLOYMENT SECTION Do you have an employment history? Yes No Are you currently employed? Yes No If no, what year were you last employed? Are you currently a volunteer? Yes No Title Organization Do you have a goal to continue your education or obtain a certification? Yes No If yes, what is your goal? Do you have any certifications or other training? Yes No List any CURRENT EMPLOYMENT (includes Volunteer) 2

3 EMPLOYMENT HISTORY Are you interested in employment opportunities in the mental health co-occurring disorders as a Peer? Yes No Is your goal to work: Full time Part time Volunteer What Barrier(s) do you identify in obtaining and sustaining work? FUTURE EMPLOYMENT GOALS Position Preferred: Residential/Supported Housing Psych Screening Center Respite Home EISS (Early Intervention) Homeless Shelter Recovery Center Self Help Center Other Specify: What Barrier(s) do you identify in a classroom setting? 3

4 How were you referred to the Consumer Connections Core Training Program? Employer (supervisor) Co-worker Peer Supported Employment Department (name) Division of Vocational Rehabilitation (DVR Counselor County) Self Help Center (name) Recovery Center (name) Mental/Behavioral Health Program Co-Occurring Program Therapist/Counselor (name) School/College Previous Core Graduate (name) Friend Neighbor Church/ministry Mental Health Association in NJ Mental Health Association Affiliate Other (please specify) I was referred to Consumer Connections Core Training Program by: Print Full Name and affiliation Last Organization Name Affiliation First Phone Are you currently receiving vocational/coaching services from any of the following programs? Supported Employment DVR (Division of Vocational Rehabilitation) Other (Name of Organization) Are you currently receiving any of the following benefits? SSI (based on disability) Social Security Insurance SSDI (based on work history) Social Security Disability Insurance General Assistance Other (Name) 4

5 REFERENCES (2 Required) Can be an employer (supervisor), peer, recovery coach, job coach, counselor, co-worker, colleague, physician or other health professional. You will need to ask them for a release of information form and sign it so they have your permission to speak with us. Notify your references that we may be contacting them. Full Name Telephone/Relationship Full Name Telephone/Relationship Print/type name Signature Date Please Mail Completed Application to: Director Consumer Connections Program Core Training Mental Health Association in New Jersey 88 Pompton Avenue, Verona, NJ For additional information, please call the following: Northern Region: Frank Garris, Trainer (908) , ext. 315 Southern Region: Maria Lambarski (973) Website: 5