CPS/CRS Interview Form
Applicant Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Interview
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-
Month
-
Day
Year
Date
Person Conducting Interview
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First Name
Last Name
Applicant county of residence
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Interview Questions
What are your reasons for wanting to work as a peer specialist?
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Please tell me about any education, training, or personal experience that prepares you for being a CPS?
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Peerstar is a recovery focused organization, how would you describe the concept of recovery to someone you were assigned to support?
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This position has been advertised for a consumer survivor of the mental health system. How would you use your own losses and recovery to instill hope in our peers?
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How willing and comfortable are you to speak with Peers about your own experiences with mental health problems and your own recovery process? How do you feel about self-disclosure?
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All of our documentation is completed on an iPad, how much experience do you have using an iPad or similar type of device?
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If i talked to your previous supervisor, what would they say are 3 strengths and 3 things you could be improving?
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Have you ever been convicted of a crime (felony or misdemeanor)? ***If YES, applicant will need to submit 2 letters of recommendation and an explanation of charges within 7 DAYS of the interview***DO NOT ASK THIS QUESTION IF APPLICANT RESIDES IN PHILADELPHIA OR PITTSBURGH***
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Yes
No
N/A
Have you ever been excluded from participation in Medicare, Medicaid, or the Pennsylvania Medical Assistance Programs?
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Yes
No
Have you completed teh 2-week certification training in Pennsylvania?
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Yes
No
Are you a Certified Peer Specialist or Certified Recovery Specialist with the Pennsylvania Certification Board (PCB)?
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CPS
CRS
Both
Neither
Have you served in the military?
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Yes
No
Do you have adequate transportation and/or a valid driver's license?
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Yes
No
How many hours are you interested in working?
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What counties/areas are you interested in working?
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How far from your home are you willing to work? (Minutes)
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What times are you available to work?
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Day
Evening
Weekends
Any
Other
Other
Check all animals applicant is comfortable working around?
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Dogs
Cats
Are you able to work around individuals that smoke?
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Yes
No
Are you interested in working with the forensic population?
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Yes
No
Are you interested in working with individuals with substance use disorder?
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Yes
No
Tell me about your experience working with, or being around someone, with an intellectual disability or autism? If no experience, put "N/A"
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Will the applicant attend Dual Diagnosis Training?
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Yes
No
Is there any specific issues/diagnosis to avoid when staffing?
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Yes
No
If yes, please list what specific issues/diagnosis to avoid
CPS Minimum Qualifications
Do they have a mental health diagnosis and have reached a place in their recovery pathway where they can positively support others in similar situation?
Yes
No
Do they have a High School Diploma or GED (Preferred)?
Yes
No
Does their resume document work/volunteer experience of at least 6 months of consecutive employment or volunteer work experience; OR within the last 3 years, has maintained at least 12 months of successful full or part-time paid or volunteer work experience? (Preferred)
Yes
No
Is the applicant an effective communicator?
Yes
No
CRS Minimum Qualifications
Do you have lived substance use history and recovery experience?
Yes
No
Do you have a minimum of 18 months of continuous recovery experience?
Yes
No
Do you regularly and actively participate in a recovery program? (All pathways to recovery are included, this does not mean you have to be involved in a 12 step recovery program)?
Yes
No
Do you have a High School Diploma or GED?
Yes
No
Do you have documentation of work/volunteer experience? (12 months of full or part-time paid, or volunteer experience within the last 36 months OR obtained at least 24 credit hours of post-secondary education)?
Yes
No
Additional Information
Reviewed onboarding schedule with applicant
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Yes
No
Do you want to hire this applicant?
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Yes
No
Unsure
Please check all items you have viewed:
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Driver's license
Social Security Card
None
Submit
Should be Empty: