CPS CEU Submission Form

Please use this form to submit documentation of Continuing Education Units for CPS-MH

Certified Peer Specialists are required to complete and provide documentation for 12 Continuing Education Units each calendar year in order to maintain active certification. For more information on CEU requirements, please visit our website.

You may use this form to upload all or part of your CEU documentation. If you have already submitted documentation of CEUs via email to ceu@gmhcn.org you are not required to resubmit them using this form.

If you have questions, please contact:

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

Full Name *

Prefix First Name MI / MN Last Name

Date of Birth *

Month Day Year

Preferred E-Mail Address *

example@example.com

Home Phone Number *

Area Code Phone Number

Cell Phone Number *

Area Code Phone Number

Mailing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PEER EMPLOYMENT STATUS

* I am currently working as a Peer Specialist *

Yes No

Agency Name

Current Job Title

Work Telephone

Work E-Mail Address

TRAINING ONE

Training One Title

Training One Facilitator

Training One Date (use first date of multi-day trainings)

Number of Continuing Education Units for Training One:

Number of CEUs/Contact Hours for Training One

Upload supporting documentation for Training One by clicking the "Browse Files" button: *

Browse Files

TRAINING TWO

Training Two Title

Training Two Facilitator

Training Two Date (use first date of multi-day trainings)

Number of Continuing Education Units for Training Two:

Number of CEUs/Contact Hours for Training Two

Upload supporting documentation for Training Two by clicking the "Browse Files" button:

Browse Files

TRAINING THREE

Training Three Title

Training Three Facilitator

Training Three Date (use first date of multi-day trainings)

Number of Continuing Education Units for Training Three:

Number of CEUs/Contact Hours for Training Three

Upload supporting documentation for Training Three by clicking the "Browse Files" button:

Browse Files

TRAINING FOUR

Training Four Title

Training Four Facilitator

Training Four Date (use first date of multi-day trainings)

Number of Continuing Education Units for Training Four:

Number of CEUs/Contact Hours for Training Four

Upload supporting documentation for Training Four by clicking the "Browse Files" button:

Browse Files

I understand that Georgia Certified Peer Specialists work from the perspective of their lived experience with recovery from a mental health diagnosis . I agree to be open about the fact that I have been diagnosed with a behavioral health concern, and to use my lived experience to support other peers along their recovery journeys. I understand that in doing so I help educate others about the reality of recovery.

I am in recovery from mental health or mental health and substance use concerns.

By printing and signing your full name below, you confirm that the information submitted on this application is true and accurate, and acknowledge that the CPS Project may terminate your participation in the CPS Project training, or revoke your certification (if received) at any time, 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.