BeHOPE Application January 2025

BeHOPE Application
If you are interested in becoming a registered Medi-Cal Peer Support Specialist please complete the application. Depending on funding availability and program requirements, some applicants may qualify for training scholarships. If you plan to request a scholarship please specify SCHOLARSHIP under "Payment method" and complete all requested information in the application. Scholarship eligibility will be based on the answer provided in the application. Please be thorough. INCOMPLETE APPLICATIONS MAY BE DELAYED OR REJECTED.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
MM/DD/YYYY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment and Household Income
Current Employment Status*

EmployedUnderemployed (Not officially employed, but still making income)Unemployed
Individual yearly Income*
Ex: 15000
Household yearly income*
Ex: 45000
Household size (include children living in the home)*
Are you a Dislocated Worker? (Laid-off or received advance notice of termination)*

YesNo

Government Assistance Information
Are you a CalWORKs/TANF Participant?*

YesNoHave applied and are waitingDecline to answer
Are you currently receiving CalFRESH (i.e. food stamps) benefits?*

YesNo
Are you an SSI/SSDI (social security) recipient?*

YesNoNot Applicable

What is your desired occupation?*
Do you give permission to share some of this information with a Job Placement and Support counselor?*

YesNo
File Upload

Cancelof
For Office Use Only

Eligible for Training ScholarshipNot eligible for training scholarshipEligible for partial scholarship
If you have a scholarship from another agency or your training is being paid for by another agency, who is paying for your training?
Should be Empty: