Peer Specialist Training Application

Peer Specialist Training Application

Richmond VA, Virginia

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Part I. timetable for application process

Thank you for your interest in the Peer Recovery Specialist Training. This training is 72 hour training with a mandatory 60 hours of classroom time, and will require class participation, tests and homework. We use the Virginia curriculum developed by the Office of Recovery Services of DBHDS and it is the training accepted by the Virginia Certification Board as part of the certification process.

There is no charge for this FIRST training, July 31st –August 7th2017. Manuals will be provided.

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.

July 7th 2017 Application Due by 1:00 p.m.

July 21st 2017 Acceptance Notification You will receive an email confirmation of acceptance

(or phone call if you do not have an email address).

July 31st 2017 Course Begins 9:00 AM

Course Location: RBHA 107 South 5th Street Richmond VA 23219

Mail applications to: Calendria Jones

Richmond Behavioral Health Authority (HOPE Program)

1700 Front Street

Richmond, VA 23222

I Prefer EMAIL

E-mail applications to:

*Please note: If emailing application, you MUST be sure page 3 is signed before emailing.

Part II. personal informatioN: Please type or print clearly

Last Name: ______First Name: ______

Home Phone: ______Cell Phone: (_____)______

Home Address: ______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: ______Work Phone: (____)______

Current job title: ______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 & recovery. I agree to be open about the fact that I have been diagnosed with a mental illness or substance use disorder. I understand that in doing so I help educate others about the reality of recovery.

______I have lived experience in recovery from a mental illness and/or substance us disorder .

______I openly identify and agree to openly disclose my history with addiction and/or mental illness & recovery.

______I am in active recovery and am using a recovery plan (such as 12 Steps or WRAP).

______I will participate fully in the entire two-week training, attend all the training modules, take tests and complete homework.

______Lunch will not be provided during the training.

______I understand that I am responsible for all meals and responsible to make all my own travel and lodging arrangements. (Lodging special rate at Comfort Inn listed)

______I understand that this Peer Recovery Specialist training is not a job placement program and that no guarantee of job placement is included as part of this training.

______I have completed this application on my own.

Part iV. signature

I certify that I have given true, accurate, and complete information on this form to the best of my knowledge.

Your signature: ______Date: ______

Please also print your name:

______

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 to attend Peer Specialist Training. Complete this form and email, fax or mail.

E-mail reference to:

Fax to: 804-321-1200

Mail reference to: Calendria Jones (CPRS)

Richmond Behavioral Health Authority (HOPE Program)

1700 Front Street

Richmond, VA 23222

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: ______

______