Re-entry and Re-Integration: Working with Justice Involved Peers (CE 101)

July 20 & 21, 2016; 9am-5pm Capital Blue Store, 4500 Marketplace Way, Enola, PA 17025 Cumberland County

Application Deadline: July 8, 2016 Cost: $425.00 Information about the Training Re-entry and Re-Integration: Working with Justice Involved Peers. The training involves both lectures and group activities. This training is designed to take your skills as a CPS and apply them with justice-involved persons in recovery who may still be incarcerated, may be about to return to their community or who are already living in the community. A CPS can serve as an important system navigator for justice-involved participants. The goal of this training is for you to gain the knowledge and skills that, woven together with your CPS background, will allow you to provide peer support to justice involved persons in recovery as they re-enter their communities in a way that is holistic, aware, ethical and effective. Topics covered in this course include:  Recognizing how we develop individual beliefs, assumptions and judgments  Using trauma informed practice  Using data to advocate for justice involved peers  Applying the appropriate response with justice involved peers according to where they are in the criminal justice process 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 or sponsoring county to confirm your attendance. MHASP/Institute for Recovery & Community Integration may share information with sponsoring agencies/organizations/entities. In order to successfully complete this course you will need to be present and participate on all of the scheduled days. Partial credit will NOT be awarded. Late arrivals or early departures will preclude successful completion. Who Should Attend /Criteria This training is for current Certified Peer Specialists who are interested in utilizing existing experience, skills and training to work with justice involved persons living with mental health, behavioral health and/or co-occurring challenges. Participation is limited to 20 individuals. If you are accepted into the training you will be contacted by the Institute for Recovery and Community Integration to confirm your attendance. Application for Working with Justice Involved Peers (CE 101) Revised 6.2.201

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I.

CONTACT INFORMATION

Full Name_______________________________________________________________ Please print name as you wish it to appear on your Certificate of Completion

Mailing Address __________________________________________________________ City___________________________________________ State ____ Zip Code_______ Phone Number (cell) ____________________ Other Number _____________________ Email (recommended) ___________________________________________

II.

DEMOGRAPHIC AND IDENTIFICATION INFORMATION

Date of birth ________________________________________ What is your race/ethnicity? (Please check all that apply to you)  African American/Black  Asian American/Pacific Islander/East Asian  Caucasian/White  Indigenous/American Indian  Latino(a)/Hispanic  Other racial/ethnicity descriptor ______________________________  Prefer Not to Answer Gender Identification  Female  Male  Transgender  Gender-Non-Conforming  Other gender descriptor  Prefer Not to Answer

III.

______________________________

WORK INFORMATION

Are you currently employed?

YES □ NO

□ YES □ NO □

Do you currently volunteer? Please, list any work or volunteer experience that you have had in the past 6 months. If there is not enough space, please continue on the back of this sheet. 1. Title/Position _________________________________________ Agency/Company _________________________________________ City & State _________________________________________ Dates Start Date ____________________ to _________

□

2. Title/Position Agency/Company City & State Dates

□

Was it paid or volunteer (check one) _________________________________________ _________________________________________ _________________________________________ Start Date ____________________ to _________ Was it paid

□ or volunteer □ (check one)

Application for Working with Justice Involved Peers (CE 101) Revised 6.2.201

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IV.

KNOWLEDGE & EXPERIENCE Are you a Certified Peer Specialist?

YES □ NO

□

Are you a certified WRAP Facilitator?

YES □ NO

When/Where was your training?

When/Where was your training?

□

V. INTEREST & INVOLVEMENT 1. Why are you interested in attending the Working with Justice Involved Peers training?

2. How will you use the information in this training?

VI. 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.)? _____________________________________________________________________________________ _____________________________________________________________________________________

VII. EMERGENCY CONTACT INFORMATION Please list two emergency contacts (people we can call if you have an emergency occur during the training): Name Relationship to you Phone Number

________________________________________________ ________________________________________________ ________________________________________________

Name Relationship to you Phone Number

________________________________________________ ________________________________________________ ________________________________________________

Application for Working with Justice Involved Peers (CE 101) Revised 6.2.201

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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 Working with Justice Involved Peers training for the entire two days. Responses to all questions on the application are my own. Finally, I understand that MHASP/Institute for Recovery & Community Integration may share information with sponsoring agencies/organizations/entities. Signature: _______________________________________

Date: ___________________

Thank you for your application. Application Deadline: July 8, 2016 Please submit any questions and your completed application to: Sarah Perez Hernandez de Conkin Administrative Assistant Institute for Recovery & Community Integration 1211 Chestnut Street, 10th floor Philadelphia, PA 19107 Phone: 267-507-3888 Email: [email protected] Fax: 215-636-6328

Please include the following to ensure timely processing of your application: ___ Completed Application (REQUIRED): Fully answer every question asked on this application. ___ Signature (REQUIRED): Remember to sign the application ___ Copy of Your Certified Peer Specialist Certificate (REQUIRED)

Application for Working with Justice Involved Peers (CE 101) Revised 6.2.201

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