Peer Specialist Training Application "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Pink Love Houston's application for training to be a Certified Peer Specialist. The cost of this 5 - day training is $600. Financial aid may be available. You will be contacted by email for next steps once your application is reviewed.Email* Name*Date of Birth* MM slash DD slash YYYY Phone Number*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Training Applying For* Mental Health Peer Specialist (MHPS) Recovery Support Peer Specialist (RSPS) Which training date are you applying for?* MM slash DD slash YYYY Are you at least 18 years old?* Yes No Do you have a high school diploma or GED?* Yes No How will you be paying for this training?* I will be paying for this training. I have a PeerForce voucher for this training. I plan to reach out to PeerForce to apply for a voucher, but will pay for my own training if I am not able to receive one. My training will be paid for by my employer or other organization I represent. My training will be paid for by the VA, TWC, TWS, or other work force development organization. I am not sure yet, but I am aware that there is a cost for training. Paying for training would be a financial hardship for me, and I would like to be considered for scholarship. Do you identify as having YOUR OWN lived experience with mental health and/or substance use challenges and recovery?* Yes No What is your concept of the role of a Peer Specialist?*Why are you interested in becoming a Certified Peer Specialist?*Describe your personal experience with recovery and how it influences your desire to support others.*What strengths or skills do you bring that would help you succeed as a Peer Specialist?*What do you do for wellness?*Emergency Contact Information (name, relationship, number)*Do you require any accommodations to participate in this training?*Untitled*Eligibility: All registrants must have personal lived mental health experience and be willing to appropriately share their experiences during the classes. Attendance: Registrants are required to be present and engaged for the duration of the entire class. Virtual Attendance: When attending classes virtually, registrants must keep their cameras on at all times to maintain an engaged and interactive learning environment. Respectful Conduct: Registrants must demonstrate respect towards the instructor and fellow students at all times." Do you acknowledge? * Yes No I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that acceptance into training does not guarantee certification. (Fill in name and date below)*
