Connection Peer Support Group

Facilitator Training Application

September 30 and October 1, 2017

Comfort Inn & Suites, Tualatin

7640 SW Warm Springs St.
Tualatin, OR 97062

Applications due Friday September 15, 2017

• Please include a letter of reference from a NAMI affiliate leader.

• Applicant must be a current NAMI member or join NAMI prior to the training.

• A phone interview will be conducted.

PLEASE PRINT LEGIBLY or Compete and Save in Microsoft Word.

Name: / Home Address:
Home Phone: / City/State/Zip:
Cell Phone: / Email:
NAMI Member? Yes: No:
Central Oregon / Clackamas County / Clatsop County / Columbia County
Coos County / Douglas County / Eastern Oregon / Klamath County
Lane County / Marion/Polk Counties / Mid-Valley / Multnomah County
Southern Oregon / Washington County / Yamhill County / Other

Do you have your own transportation? Yes: No: Use public transportation? Yes: No:

Job Requirements:

Identify as being in recovery from a mental illness

Attend a meeting of an existing NAMI Connection support group prior to the training if possible

Attend the entire 2-day facilitator training

Adhere to the NAMI Connection Peer Support Group model when facilitating a group

Commit to facilitatinga support group for a minimum of one year

Provide participant data to NAMI Oregon following each support group meeting

Be willing to identify potential new facilitators from support group participants

Have a positive regard for or personal experience with mutual support

Be or become a member of NAMI prior to the training

I have read and agree to the NAMI Connection Peer Support Group Facilitator job requirements.

Availability to facilitate a support group (please check all that apply):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Morning
Afternoon
Evening

Participant Survey

Are youan individual living with mental illness? / Yes No
Yourdiagnosis is:
Have you ever been convicted of a felony? / Yes No

If yes, please explain:

Have you participated in a Connection PeerSupport Group? / Yes No

Have you taken other NAMI classes or trainings? Please list below.

Please briefly describe why you want to become a Connection Peer SupportGroup facilitator:

Lodging/Dietary Needs

Do you require a handicapped-accessible training facility? / Yes No
Do you require lodging for the training? / Yes No
Do you require a handicapped-accessible hotel room? / Yes No
Are you willing to share a room* (if hotel accommodations are offered)? / Yes No
If hotel offered, you would like to share with:

*For trainees travelling 50 miles or farther, NAMI Oregon will arrange and pay for double-occupancy lodging near the training site. Trainees requiring private rooms will need to arrange and pay for their own lodging. If you accept lodging offered by NAMI Oregon but must withdraw from the training before it begins, you MUST contact NAMI Oregon ASAP so the lodging reservation can be canceled without paying a penalty. Lodging is not provided for trainees who live in the Portland metro area.

Please list any special needs for accommodations or meals, including food or other allergies*:

*Some meals, snacks, and beverages are provided throughout the training. Consult the training schedule to see which meals are provided. When possible, NAMI Oregon will accommodate dietary restrictions. Trainees with extensive dietary restrictions should plan to supplement the food provided by bringing items from home.

Return Applications and Letters of Reference to:

Peter Link

NAMI Oregon

4701 SE 24th Ave., Suite E

Portland, OR 97202

Fax: 503-230-2751
Email:

Page 1 of 3Connection Facilitator Training Application

rev. Aug. 2016

4701 SE 24th Ave., Suite E, Portland, OR 97202

503-230-8009