Application for Certified Peer Specialist (CPS) Training Program 283 Butler Rd, Mt Gretna, PA 17064 (Lebanon County) Dates: May 8-12 & May 22-26, 2017 9am-5pm Application Deadline Extended: May 1, 2017 Cost: $1375.00 Information about the Training The Peer Specialist Certification Training is a ten day course. The curriculum focuses on education, skill building, and providing an experiential group process for training participants. By participating in the training, participants will: • Gain new knowledge and understanding of recovery, the peer support movement, trauma informed care, Wellness Recovery Action Plan (WRAP), Whole Health Action Management (WHAM),; • develop new skills around engagement, outreach, ethics and boundaries, disclosure, documentation; • increase personal awareness; • enhance personal recovery. Qualification for certification includes successfully completing a written test at the end of each week, full engagement in classroom discussions and participation in 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. 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. If you are accepted into the training program you will be contacted by the Institute for Recovery and Community Integration to confirm your attendance. 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.

Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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Who Should Attend /Criteria The most recent Bulletin, OMHSAS-16-12 identifies the following criteria to be trained as CPS: (a) Be self-identified individuals who have received or are receiving mental health services for a serious emotional disturbance or serious mental illness. (b) Eighteen (18) years of age and older. (c) Have a high school diploma or general equivalency diploma and (d) Within the last three (3) years, have either maintained at least 12 months of successful work or volunteer experience, or earned at least 24 credit hours at a college or post-secondary educational institution.

Definitions: Serious Emotional Disturbance (SED) – A condition experienced by a person under 18 years of age who currently or at any time during the past year had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the current Diagnostic and Statistical Manual; and that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities. Serious Mental Illness (SMI) - A condition experienced by persons 18 years of age and older who, at any time during the past year, had a diagnosable mental, behavioral, or emotional disorder that met the diagnostic criteria within the current DSM and that has resulted in functional impairment and which substantially interferes with or limits one or more major life activities. Adults who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are considered to have serious mental illness. Substance use disorders and developmental disorders are not included.

Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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I. CONTACT INFORMATION Full Name_______________________________________________________________ Please print name as you wish it to appear on your Certificate(s) 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 Do you have a valid Pennsylvania Driver’s License? Are you a veteran of the United States Armed Forces? If yes, dates served ___________________________________ Branch _____________________________________________

YES □ NO

□ YES □ NO □

Are you a family member of someone who has served or is currently serving in the United

YES □ NO

States Armed Forces?



Have you received services from the Office of Vocational Rehabilitation within the past three

YES □ NO

years? Do you receive SSI and/or SSDI benefits?

□ YES □ NO □

Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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NOTE: The information requested in the next three sections are set by Office of Mental Health and Substance Abuse Services (OMHSAS) and are mandated criteria for certification as a Certified Peer Specialist. III. EDUCATIONAL HISTORY Check all that apply and provide the years you attended (ex. 1995-1999):  High School/GED Years Attended _______  Associates Degree Years Attended _______  Bachelor’s Degree Years Attended _______  Master’s Degree or beyond Years Attended _______  Other Education or Training Programs Years Attended _______ IV. EMPLOYMENT HISTORY Please, list any work or volunteer experience that you have had in the past 3 years. If there is not enough space, please continue on the back of this sheet. 1. Where ______________________________________________________ Date - From ____________________ to __________________________ Was it paid

□ or volunteer □ (check one)

2. Where ______________________________________________________ Date - From ____________________ to __________________________ Was it paid

□ or volunteer □ (check one)

3. Where ______________________________________________________ Date - From ____________________ to __________________________ Was it paid

□ or volunteer □ (check one)

4. Where ______________________________________________________ Date - From ____________________ to __________________________ Was it paid

□ or volunteer □ (check one)

Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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V.

MENTAL HEALTH CONSUMER HISTORY*: Please select the response that reflects your lived experience. *Lived experience of Substance Use Treatment by itself 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 serious emotional disturbance. OR  I personally identify as someone who is a present or past recipient of mental health services for a serious mental illness or serious emotional disturbance AND substance use abuse

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.)? Please describe. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ VII. Emergency Contact Information Name ______________________________________________ Relationship to you ______________________________________________ Phone Number _______________________________________________ Other Phone Number _______________________________________________ VIII.

Short Essays: Please think about and answer the following questions. Each answer should be about 50 words.

1. One key to recovery is the use of natural supports in your life. Please describe the definition and role natural supports play in your life?

2. What makes a CPS unique and how does their role differ from other positions in Behavioral Health?

Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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3. A key role for the CPS is to minimize stigma and be an ambassador for recovery. Describe a situation where you had to confront stigma.

4. Describe how working as a Certified Peer Specialist fits into your current life plans/goals?

5. What will be your greatest challenge in attending the CPS training from 9am-5pm for the entire ten (10) day period? What is your plan for addressing the challenge? Please be as specific as possible.

IV. Full payment is required prior to training. Please indicate how you will be paying for the Certified Peer Specialist training. An invoice will be sent once accepted into the training. MHASP/Institute for Recovery & Community Integration may share information with sponsoring agencies/organizations/entities.  Self: Invoice will be mailed to mailing address listed on application.  Office of Vocational Rehabilitation (OVR) Send invoice to: OVR District ____________________________________________ OVR Contact Name ____________________________________________ Address ____________________________________________ Phone ____________________________________________ Email ____________________________________________  Sponsoring Agency or Company Send invoice to: Name of Agency/Company ____________________________________________ Agency Contact Name ____________________________________________ Address ____________________________________________ Phone ____________________________________________ Email ____________________________________________  Other

_____________________________________________ Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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Send invoice to: Name Address Phone/Email

____________________________________________ ____________________________________________ ____________________________________________

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. Finally, I understand that MHASP/Institute for Recovery & Community Integration may share information with sponsoring agencies/organizations/entities. Applicant Signature: _________________________________________

Thank you for your application. Please submit any questions and your completed application to by April 24, 2017: 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.  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  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.  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. Application for Certified Peer Specialist Training Program (Lebanon County-May 2017) Revised 1.9.2017

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CPS Application_Lebanon County_May 2017.pdf

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