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. Six of those CEUs must come from a GMHCN sponsored training, workshop and or conference. For more information on CEU requirements, please visit our website.

Use this form to upload all of your CEU documentation. Please DO NOT submit documentation of CEUs via email. Any CEUs received via email as of August 15th, 2024 will not be accepted.

If you have questions, please contact:

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

PrefixFirst NameMI / MNLast Name
Date of Birth*

MonthDayYear
Preferred E-Mail Address*
example@example.com
Home Phone Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please select the DBHDD Region that you reside in*

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)
Demographic Information
Sex*

FemaleMaleOther
Race*

American Indian or Alaska NativeAsianAfrican American or BlackHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
CPS Training Cohort Number*
Go to https://www.gmhcn.org/cps-training-schedule and move bottom to locate your Cohort Number
Employment Information
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 ONE
Training One Title
Training One Facilitator
Training One Date (use first date of multi-day trainings)
Number of CEUs/Contact Hours for Training One
Upload supporting documentation for Training One by clicking the "Browse Files" button:*

Browse Files

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Training Two
Training Two Title
Training Two Facilitator
Training Two Date (use first date of multi-day trainings)
Number of CEUs/Contact Hours for Training Two
Upload supporting documentation for Training Two by clicking the "Browse Files" button:

Browse Files

Cancelof

Training Three
Training Three Title
Training Three Facilitator
Training Three Date (use first date of multi-day trainings)
Number of CEUs/Contact Hours for Training Three
Upload supporting documentation for Training Three by clicking the "Browse Files" button:

Browse Files

Cancelof

Training Four
Training Four Title
Training Four Facilitator
Training Four Date (use first date of multi-day trainings)
Number of CEUs/Contact Hours for Training Four
Upload supporting documentation for Training Four by clicking the "Browse Files" button:

Browse Files

Cancelof

Training Five
Training Five Title
Training Five Facilitator
Training Five Date (use first date of multi-day trainings)
Number of CEUs/Contact Hours for Training Five
Upload supporting documentation for Training Five by clicking the "Browse Files" button:

Browse Files

Cancelof
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*

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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.

Contact Information

Demographic Information

Employment Information