Training Enrollment

Full Name:*

Birth Date:*

Date

Email:*

example@example.com

Phone Number:*

Can a message be left on this phone?*

YesNo

Address:*

Name of Case Worker:

Clinic:

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

Are you applying for this training because you intend to practice or deliver peer support services in an employment setting?*

YesNo

Are you currently employed as a Peer Support or have a position waiting for you upon completion of training?*

YesNo

If yes, where?

Are you currently employed?*

YesNo

If yes, where are you employed?

Do you have a high school diploma or GED or are you currently in the process of obtaining a GED?*

YesNo

Do you need more information on payment options or the referral process?*

YesNo

This training will require attendance of all units, some outside assignments, and facilitation of a group. The training requires interactive role playing,activities, reading aloud to the group and sharing your recovery story. Are you able to complete this and to be present every day of training?*

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? *

Do you self-identify as having a lived experience of mental health disorders,substance use disorders and/or traumas associated with significant life disruptions?*

YesNo

Are you actively working on your recovery and managing your Wellness?*

YesNo

Are you willing to share these lived experiences when appropriate for purpose of education and to model recovery? This will include sharing what you have overcome, what has helped you move forward in your recovery, what a diagnostic label means to you, how you would keep yourself safe during a personal crisis,and some of the values and beliefs you have developed in your recovery.*

YesNo

You will listen to others recovery stories which can be triggering and some details can be uncomfortable, are you willing to communicate any discomfort to the trainer if this happens?*

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