CEU Approval Request Form

Outside Training CEU Approval Form
All Certified Peer Specialist- Mental Health must submit 12 continuing education units (CEUs) to remain active in the State of Georgia. Six (6) of those CEUs must come from a GMHCN training or a GMHCN sponsored training. GMHCN will accept peer focused and strengths based CEUs from Georgia Parent Support Network, Georgia Council for Recovery, Mental Health Technology Transfer Center (MHTTC), Prevention Technology Transfers Center (PTTC), Doors to Wellbeing, certain Relias Trainings and certain DBHDD trainings. Please visit our website to view a list of approved training vendors.

Trainings outside of the agencies listed above, must be submitted for review and approval by the Chief Training and Development Officer and CEU coordinator. The following form must be filled out in its entirety. Please DO NOT submit documentation of CEUs via email. For more information on CEU requirements, please visit our website.

If you have questions, please contact:

Continuing Education Coordinator
Georgia Certified Peer Specialist Project
Phone: 404-687-9487
E-mail: ceu@gmhcn.org
Contact and Employment Information
Name

First NameLast Name
E-Mail Address*
example@example.com
Phone Number*

Area CodePhone Number
PEER EMPLOYMENT STATUS
* I am currently working as a Peer Specialist*

YesNo
Agency Name
Current Job Title
Work Telephone
Work E-Mail Address
Please select the DBHDD Region where you work, volunteer, and or provide services*

Region 1 (Dade, Walker, Catoosa, Chattooga, Whitfield, Murray, Gordon, Floyd, Bartow, Polk, Paulding, Haralson, Cobb, Douglas, Fannin, Gilmer, Pickens, Cherokee, Union, Lumpkin, Dawson, Forsyth, Towns, White, Hall, Rabun, Habersham, Banks, Stephens, Franklin, Hart)Region 2 ( Jackson, Madison, Elbert, Barrow, Walton, Morgan, Oconee, Clarke, Oglethorpe, Greene, Wilkes, Taliaferro, Warren, McDuffie, Lincoln, Columbia, Richmond, Glascock, Jefferson, Emanual, Burke, Jenkins, Screven, Jasper, Putnam, Hancock, Baldwin, Washington, Wilkinson, Jones, Monroe, Bibb, Twiggs)Region 3 ( Clayton, Dekalb, Fulton, Gwinnett, Newton, Rockdale)Region 4 (Terrell, Calhoun, Early, Miller, Lee, Dougherty, Baker, Worth, Seminole, Decatur, Mitchell, Grady, Thomas, Colquitt, Turner, Tift, Cook, Brooks, Ben Hill, Irwin, Berrien, Lanier, Lowndes, Echols)Region 5 ( Bleckley, Pulaski, Wilcox, Dodge, Laurens, Telfair, Wheeler, Montgomery, Treutlen, Johnson, Coffee, Atkinson, Clinch, Bacon, Ware, Pierce, Charlton, Brantley, Toombs, Appling, Wayne, Candler, Tattnall, Evans, Bulloch, Long, Liberty, Bryan, Effingham, Chatham, McIntosh, Glynn, Camden)Region 6 (Carroll, Heard, Troup, Coweta, Meriweather, Harris, Muscogee, Chattahoochee, Stewart, Quitman, Clay, Randolph, Talbot, Fayette, Spalding, Pike, Upson, Lamar, Henry, Butts, Crawford, Peach, Houston, Taylor, Marion, Webster, Schley, Sumter, Macon, Dooly, Crisp)
Training Information

Please answer the below information regarding the training you are seeking CEU approval. If you received CEUs for a conference, please provide the below information for ALL sessions attended.
TRAINING ONE
Training Title*
Training Facilitator*
Training Provider/Organization*
Training Start Date *
Training End Date *
Type of Training*

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)*
Training Description*
Training Learning Objectives*
How does this training align with your professional development goals?*
How will the knowledge/skills gained from this course benefit your current role?*
Please specify any certifications or licenses that this course will help maintain or obtain.*
Number of CEUs/Contact Hours Requesting*
Upload supporting documentation for Training One by clicking the "Browse Files" button:*

Browse Files

Cancelof

TRAINING TWO
Training Title
Training Facilitator
Training Provider/Organization
Training Start Date
Training End Date
Type of Training

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)
Training Description
Training Learning Objectives
How does this training align with your professional development goals?
How will the knowledge/skills gained from this course benefit your current role?
Please specify any certifications or licenses that this course will help maintain or obtain.
Number of CEUs/Contact Hours Requesting
Upload supporting documentation for Training Two by clicking the "Browse Files" button:

Browse Files

Cancelof

TRAINING THREE
Training Title
Training Facilitator
Training Provider/Organization
Training Start Date
Training End Date
Type of Training

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)
Training Description
Training Learning Objectives
How does this training align with your professional development goals?
How will the knowledge/skills gained from this course benefit your current role?
Please specify any certifications or licenses that this course will help maintain or obtain.
Number of CEUs/Contact Hours Requesting
Upload supporting documentation for Training Three by clicking the "Browse Files" button:

Browse Files

Cancelof

TRAINING FOUR
Training Title
Training Facilitator
Training Provider/Organization
Training Start Date
Training End Date
Type of Training

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)
Training Description
Training Learning Objectives
How does this training align with your professional development goals?
How will the knowledge/skills gained from this course benefit your current role?
Please specify any certifications or licenses that this course will help maintain or obtain.
Number of CEUs/Contact Hours Requesting
Upload supporting documentation for Training Four by clicking the "Browse Files" button:

Browse Files

Cancelof

TRAINING FIVE
Training Title
Training Facilitator
Training Provider/Organization
Training Start Date
Training End Date
Type of Training

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)
Training Description
Training Learning Objectives
How does this training align with your professional development goals?
How will the knowledge/skills gained from this course benefit your current role?
Please specify any certifications or licenses that this course will help maintain or obtain.
Number of CEUs/Contact Hours Requesting
Upload supporting documentation for Training Four by clicking the "Browse Files" button:

Browse Files

Cancelof

TRAINING SIX
Training Title
Training Facilitator
Training Provider/Organization
Training Start Date
Training End Date
Type of Training

WorkshopSeminarOnline CourseConferenceOther
Course Duration (Hours)
Training Description
Training Learning Objectives
How does this training align with your professional development goals?
How will the knowledge/skills gained from this course benefit your current role?
Please specify any certifications or licenses that this course will help maintain or obtain.
Number of CEUs/Contact Hours Requesting
Upload supporting documentation for Training Four by clicking the "Browse Files" button:

Browse Files

Cancelof

ACKNOWLEDGEMENT
I understand that Georgia Certified Peer Specialist-Mental Health work from the perspective of their lived experience with recovery from a mental health diagnosis and/or challenges.

I agree to be open about the fact that I have been diagnosed or live with a behavioral health challenge, and to use my lived experience to support other peers along their recovery journeys, as stated in the Certified Peer Specialist-Mental Health Code of Ethics.

I understand and acknowledge that as a CPS-MH, it is my responsibility to keep my certification active by maintaining the minimum CEU requirements that has been set before me and I agree to abide by and uphold the CPS-MH Code of Ethics.

Certified Peer Specialist- Mental Health Code of Ethics
By printing and signing your full name below, you confirm that you have read the above acknowledgement statements and the information submitted on this application is true and accurate. You understand and acknowledge that the CPS Project may terminate your participation in the CPS Project training, or move your certification status to inactive, if it is determined that false information was supplied on this form.
Print your full name here:*
Signature*

Clear
You will receive a confirmation response after you click the "Submit My CEUs" button that will indicate that your submission has been received. You will also receive a confirmation email from the Georgia CPS Project which will be sent to the "preferred email" that you entered in your application.
Should be Empty:

Contact and Employment Information

Training Information