L.A. CADA PEER SPECIALIST PILOT TRAINING
I certify that I meet the following criteria:
*
I have lived experience (substance use, mental health, or both, personally, or through family)
I am committed to attend and participate in the schedule of instruction
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Date
Employer:
Supervisor's Name:
First Name
Last Name
Funding Source:
CalMHSA Scholarship
American Job Career Center
Incumbent Worker Program
I would like to apply for funding
Self Pay
Other
Specify Other Funding Source:
*
Are you currently employed?
Please Select
Full Time
Full Time – Community Based Organization
Full Time – Behavioral Health County Agency
Full Time - Other
Part Time
Part Time – Community Based Organization
Part Time – Behavioral Health County Agency
Part Time – Other
Unemployed
Do you have high school diploma or GED?
*
Please Select
High School Diploma
GED
None
What's your gender identity
Please Select
Male
Female
Non-Binary
Decline to Answer
What's Your Race/Ethnicity?
American Indian/Alaskan
Asian/Pacific
Black
Hispanic
White
Not Reported
Do you speak any other languages fluently?
Arabic
Armenian
Cambodian
Chinese
English
Farsi
Hindi
Hmong
Japanese
Korean
Lao
Punjabi
Russian
Spanish
Tagalog
Thai
Vietnamese
Other
Please specify "other" language(s):
Disability:
Yes
No
Decline to answer
Veteran:
Yes
No
Sexual Orientation:
Heterosexual
Gay
Lesbian
Bisexual
Two-Spirit
Queer
Questioning
Intersex
Asexual
Pasexual
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