Training Enrollment

Full Name:*

Birth Date:*

Date

Email:*

example@example.com

Phone Number:*

Format: (000) 000-0000.

YesNo

Address:*

Name of Case Worker:

Clinic:

How did you hear about NAZCARE’s Peer Support Training?

YesNo

If yes, where?

YesNo

If yes, where are you employed?

YesNo

Are there any barriers which may prevent you from completing training or any accessibility accommodations you may need in order to participate? *

What will be your most difficult challenge while participating in this training, and how will you address it? *

YesNo

What experience do you have with recovery? For how long? This could include mental illness, substance abuse, and more either with yourself or others around you.*

How do you imagine this training could, positively or negatively, impact your own life and relationships?*

The training is intended to prepare you to practice and deliver peer support services in the AHCCCS (Medicaid) programs. When and why did you decide to become a PRSS?*

A PRSS often spends a lot of time on documentation, and may have other duties unrelated to practicing and delivering peer support services. Some of the environments you perform these duties in may be less welcoming and may seem less Recovery-oriented. What reservations do you have about duties and environments as a PRSS?

By signing below, I understand that I must complete all aspects of training with satisfactory performance to receive my credential. If I do not, I will not receive a credential and I will not receive a refund. I understand that completion of this training does not guarantee me a position with NAZCARE nor any other agency. I have completed all of the above questions and information to the best of my knowledge.*

Date Signed:*

Date

Please attach a copy of a state issued picture ID and Insurance Card (when applicable) when submitting this application.

Optional License Photo (if on mobile device):

NAZCARE Inc. Training Application