MHPS-Standard Application for Mental Health Peer Specialist Training

Date

MonthDayYear

Choose date for class.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1. Do you have a minimum education of a GED or High School Diploma?

2. Are you a Texas Resident?

3. Are you 18 years of age or older?

4. Do you have lived experience with a mental health condition?

5. Are you willing and able to appropriately share your mental health recovery story?

6. Are you (choose all that apply)

Other

7. If you are in recovery from a mental health condition, how long have you been in recovery?

8. Tell us briefly about your mental health recovery story (limit 150 words)

9. Are you currently volunteering or working at an organization that provides Recovery Support Services?

a. If not, how do you plan on using your Mental Health Peers Specialist training?

b. If so, what Organization are you working/volunteering at? Please provide Organization name, Supervisor name and phone #

10. What is your purpose for taking this training?

If you selected a or b please fill out the following information Please provide Organization name, Supervisor name and phone #

11. In addition to your experience, what other ways can people experience/find recovery?

12. Is there anything you wish to share, such as experience of trauma or life disruptions Please do so at your comfort? Please indicate if you do not wish to share/have nothing to share at this time, though one of the requirements of the class is that you must be willing to appropriately share your recovery story.

By signing and submitting this application I acknowledge that my role as a Mental Health Peer Specialist is and must be completely separate from any other role, including that of clinician or sponsor. I also acknowledge that recovery is self-guided and that my role as an MHPS may include assisting others on their chosen path, whether that includes abstinence based, medication assisted, harm reduction, or any other path to recovery.

Date

MonthDayYear

ADDITONAL IMPORTANT INFORMATION:

If none of the above is complete you will not receive your certificate of completion until it is completed.

Any questions please contact:

Peter McCarthy 210-551-1733 pmccarthy@sacada.org

Esteban Romo 210-550-5815 eromo@sacada.org

Antoinette Ruffing 210-287-3820 aruffing@sacada.org

Standard Application for MHPS Training

Please answer the following questions: