Peer Mentoring Training Programme

Application Form

Please complete all the sections and return to Edward Field, 61 Munster Road, Fulham SW6 5RE or 07500112161

Post applied for:Peer Mentor (Hammersmith & Fulham drug & alcohol services)

Personal Details

Name...... Telephone: Home......
Address...... Mobile phone: ………………………………
...... Email…………………………………………
......
......
......
Date of birth......
Support
Please provide the name of your current or most recent keyworker and service(s) that you arecurrently accessing and are planning to continue to access for support:
......
......
......
......
…………………………………………………………………………………………………………...

Education

General Education (i.e. school level)
Subject / Qualification / Grade / Year obtained
Further Education (i.e. college/university level)
Details / Year obtained
Qualifications currently being studied for
Details / Exam date (s)

Work experience

Please include both paid employment and voluntary work experience

(Continue on a separate sheet if necessary)

Present/most recent work experience
Company Name and Address:
Telephone:
Post held:
Date from:Date to:
Staff category:Full time  Part time  Casual/Locum Voluntary Agency 
Duties and responsibilities:
Reason for leaving:
Manager’s name (who can provide a reference)
May we contact them before interview? YesNo 
Other work experience
Company Name and Address:
Telephone:
Post held:
Date from:Date to:
Staff category:Full time  Part time  Casual/Locum Voluntary Agency 
Duties and responsibilities:
Reason for leaving:
Manager’s name (who can provide a reference)
May we contact them before interview? YesNo 
Referees
Please supply details of two people who could provide references for you. We are unable to accept references from a family member or personal friend. Referees must be relevant and appropriate, where there is no employment history a character reference could be supplied by a college tutor, key worker, church minister or from a voluntary work position.
If you are struggling to find referees please speak to a member of the Peer Mentor Training team.
1st Referee / 2nd Referee
Name: / Name:
Address:
Telephone number:
E-mail:
In what capacity do they know you? / Address:
Telephone number:
E-mail:
In what capacity do they know you?

1

Reason for application and additional information
Please outline below why you feel you would like to become involved in Peer Mentoring and provide details of any relevant skills and experience.
For example details of any direct work or support to young people, people with substance/alcohol misuse issues, homelessness, ex-offenders; the use of counselling or facilitation skills; liaison with statutory and voluntary organisations; issues related to mental health and emotional well-being.
Experience is not only gained through full-time work. Experience can also be gained through other voluntary work, part-time work, college or school based projects, clubs or home life etc.
Please use Peer Mentor Requirements(attached) as a guide when completing this section
Please attach additional sheets if more space is required.
Please use this space to give any information you would like to include in support of your application including details of your interests and activities.

1

General

Do you have a current driving licence?YesNo 
Do you need help with the following? If yes, please provide a brief explanation:
Literacy Y N
Numeracy Y N
ICT Y N

If you are not an EU citizen do you have a work permit?YesNo 
If yes, expiry date of work permit:
Are you related to, or do you live with, any of our employees in the Hammersmith and Fulham treatment system?
YesNo 
If yes please give details:
THE REHABILITATION OF OFFENDERS ACT 1974 - All convictions, including "spent convictions", MUST be disclosed for the purpose of this application
Have you ever been convicted of a criminal offence?YesNo 
If yes please give details, most recent first, includingdate and nature of conviction:
Please give details of all Cautions you have received:
In the event that your application is successful a Disclosure and Barring Service (DBS) check will be required, however please be assured that a criminal record will not necessarily be a bar to your obtaining a position as a Peer Mentor

Declaration

The information I have given in this application is, to the best of my knowledge, accurate.
I understand that false or misleading information will affect my application to become a Peer Mentor.
SignatureDate

Check-list:

Before sending off your application form, please make sure that you have:

  • Supplied details of two referees
  • Included the Interview Assessment Checklist which has been completed and signed by your key worker
  • Provided us with a telephone number that we can contact you on
  • Signed the Peer Mentoring Information Sharing Consent form

If you have difficulties completing this application form, please contact either Chris Franks at CRI Munster Road or the Peer Mentor Champion/Lead at your support service.

1

Peer Mentoring Information Sharing Consent Form
I ______consent to the Peer Support Working Group contacting the following agencies in relation to my application to the Peer Mentoring Programme (including referral agent)
And for these agencies to share information about me with the group and vise versa. I understand that only information relevant to my participation or progression on the Peer Mentoring Programme will be shared.
Information that I have provided is to be held on file according to the Data Protection Act. It may be used as part of the assessment for my application or in relation to my support on the programme. I understand that information received will remain confidential to the group and other organisations working with them.
I understand that information may be shared without my consent in the event that:-
  • A child may be at risk
  • Other parties may be at risk
  • Disclosure of a serious crime
Signed…………………………………………………….. Date………………………………………
Printed Name………………………………………………………………..

Peer Mentoring - Assessment Checklist for Keyworkers

Yes / No / If yes please give details. / Risk Score (1=low / 5=high)
1. Does the applicant have any criminal convictions in the last 3 months? / 1-2-3-4-5
2. Is the applicantcurrently involved with the criminal justice system? If so, when does this end? / 1-2-3-4-5
3. Is the applicant currently receiving any prescription drugs (Methadone / Buprenorphine) from a GP or a Drug Treatment Service? / 1-2-3-4-5
4. If so, at what level and please give details of any reduction programme they are on / 1-2-3-4-5
5. Has the applicant used illicit drugs or alcohol in the last 6 months? / 1-2-3-4-5
6. Is the applicant currently involved with Drug Treatment Services? If so which one/s / 1-2-3-4-5
7. Does the applicant currently suffer from any mental health issues i.e depression/self harm/panic attacks/anxiety? If so, is he/she taking any medication prescribed by their GP for this? / 1-2-3-4-5
8. Is the applicant living in stable accommodation at present? What kind of accommodation? Is support provided? / 1-2-3-4-5
9. Is there anything else you feel could present a risk? / 1-2-3-4-5

Risk Level Score: …………………(potential maximum score 45)

Signed: Keyworker…………..……………………………………DATE:……….……...

Name:

Signed: Peer Mentor Applicant………………………………….DATE:……………....

Name:

Peer Mentor Requirements

Please consider the following when completing your application form and writing your support statement:

To be able to demonstrate stability in addressing your own alcohol or substance misuse issues.

To have a minimum of 3 months abstinence from illicit substances and/or your substance of choice.

If you are on substitute prescribing to be on a maximum of 30mls methadone/3mg Subutex) and actively engaged with a reduction plan.

To have achieved stability in addressing any offending behaviour.

To have commitment to continued work on personal recovery issues.

To be able to attend the 12 weeks (1day per week) of training, plus additional supervision sessions.

To commit to a 6 month placement (minimum of one day per week) and additional supervision sessions/training.

To demonstrate a readiness to take part: - this will include motivation, time keeping skills, attendance, reliability, concentration, ability to work with others.

Good verbal and written communication skills (some support can be provided).

Some understanding of the issues and willingness to work with the client group.

Basic computer and keyboard skills (this can be developed through training).

Able to respect and maintain confidentiality.

Ability to work within in professional boundaries.

A non-judgmental attitude and willingness to increase awareness of discrimination and diversity.

Willingness to reflect on your own practice.

1