2. Mailing Address:Street, City, State, Zip

TAKE YOUR HEART T WORK®

NCCPSS Training Application

1. Name:

2. Mailing Address:Street, City, State, zip

3. Email Address:

4. Telephone Number (cell):

5. Are you in Recovery from mental health diagnoses or substance use disorder (substance abuse)? y n

Recovery date, if applies:

6. Are you employed? y n Employer:

7. Are you a student? y n Name of School:

8. Are you active military or a veteran? y n

9. Are you registered with Vocational Rehabilitation? y n If yes, contact your counselor and ask about funding for this training. Name and contact of your counselor.

10. List certified trainings you have graduated from in the past 2-3 years:

11. As part of your application, write 1-2 paragraphs about why you want to take this training, what are your expectations and what “Take Your Heart to Work” means to you.

12. Prerequisites (completed before Peer Support Specialist training ):

1. Graduation from one certified wellness plan training is a prerequisite for the Take Your Heart to Work Training. It must be a certified plan that you write for yourself to help you monitor your wellness. The following are examples of accepted training:

A. A recent 16-20 hour Copeland Center Wellness Recovery Action Plantraining. This agency has Copeland Center Trainers. Send questions to . Cost is $50.00.

B. A recent 20 hour NAMI Peer to Peer training.

C. Other 16-20 hourcertified wellness plan training. Explain for approval.

A graduation certificate or proof of completion of one of the above is required on day one of training.

2. Completionof an online Advanced Assignment and submitted to Gin Monroe one week prior to Day 1 of Training.

Topics include Taking Care of Yourself and History of the Peer Movement.

Note: Accommodations will be made to those who do not have access to the internet.

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Submit your application to Gin Monroe at at least 4 weeks in advance.You will receive an acceptance letter if you are approved to take the training. You will also receive the Advanced Online Assignment 2-3 weeks before the training. If you do not receive these documents, you will need to wait for another training.

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Cost per person for the Take Your Heart to Work , Peer Support Specialist Training is $375.00, due when accepted in the training.

If payment is not made 2 weeks in advance of the training, your name will be removed from the registration list.

Payment can be made to Monroe Consulting, LLC and mailed to 429 Neuchatel Road New Bern, NC 28562

Limited partial scholarships are available upon request. Other sources of funding include: Mental Health Association, College, Mental Health Agency, Consumer and Family Advisory Board, Governor’s Institute on Substance Abuse, Managed Care Organization, Vocational Rehabilitation, etc.

Notify trainers or Gin Monroe if you are unable to attend a training. We usually have a waiting list and would like to give others the opportunity to attend.

Reasonable accommodations are made for all people.

I have read this application and agree to the terms: ______

Participant’s Signature and date