Form
Peer 2 Peer: Journey to Wellness Peer Recovery Specialist Certification Course Application Form
Name
First Name
Middle 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
Pronouns
Birthday
-
Month
-
Day
Year
Date
Ethnicity
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Please identify your lived experience as either:
1. Substance Use Disorder 2. Mental Health Condition 3. Co-occurring
Type Answer Here
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Describe why you would like to become a CRPS.
Share a specific experience where you provided support or encouragement to someone facing mental health challenges. What did you learn from this experience?
Propose an innovative project or initiative you would implement as a Peer Recovery Specialist to enhance the well-being of individuals in the community.
If your journey in learning about mental health were a map, what landmarks or milestones would be on it, and how have they prepared you for this course?
Describe a personal challenge you have overcome and how it has contributed to your resilience and ability to empathize with others.
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Draft a personal mission statement highlighting your commitment to promoting mental health and peer recovery.
Describe a passion or hobby that you believe contributes positively to your mental health. How does this passion inform your approach to peer recovery?
Share a book, movie, or quote that has significantly influenced your perspective on mental health and recovery. Explain its impact on you.
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Personal Reference
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Professional Reference
Name
First Name
Last Name
Position
Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Additional Info
Please provide your current employer and/or volunteer position information:
Employer
Position
Duration of Service
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Volunteer Position
Organization
Position
Duration of Service
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any misrepresentation may lead to the rejection of my application.
Signature
I acknowledge that participating in and completing all the modules within this 40-hour course is mandatory to obtain the CRPS credential.
Accept
I acknowledge that participation in and completing all the modules within the 40-hour Peer2Peer course as well as having 16-hours of WRAP training is mandatory to obtain the CRPS credential.
Accept
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