Peers: Link to HOPE Initiative

Certified Peer Specialist Employment Training Application

Office only—Date received______/Com. Date______

Preferred Training Location (if any): ______

Preferred Training Dates (if available):______

Please mail, email or fax application* to: Peers: Link to HOPE Initiative

Attn: Judy Benham

3130 SE 2nd Ave

Grand Rapids MN 55744

Fax: 218-999-4041

Email:

For questions about the application or trainings, please contact Judy Benham, 218-999-4012 or for other questions: Taylor Jackson, Director of Peers: Link to HOPE Initiative—218-244-4717 /

*Please note, submission of CPS Employment Training application does not guarantee acceptance into the training. A written notification of acceptance decision will be provided in 30 days or less from submission date.

Applicant’s Contact Information (please type or handwrittenCLEARLY with a black ink pen)

Full Name:
Mailing Address:
City : State: Zip Code :
Email Address:
Cell Phone: ( ) Home Phone: ( )
Work Phone: ( ) Best time to call: AM NOON Afternoon PM

Eligibility Factors

Please write your initials in the appropriate response box (Yes or No).

Eligibility Questions / Yes / No
Are you 21 years or older?
Are you able to complete this application independently?
Do you have a first-hand lived experience with a mental illness?
Have you been hospitalized due to symptoms related to your mental illness diagnosis within the past 6 months?
Have you been to treatment due to symptoms of a chemical dependency diagnosis within the past 12 months? (Support groups NOT included)
Do you agree to be willing and able to disclose your diagnosis and experience with living with a mental illness for the purpose of education, role-modeling, and providing hope to others about the reality of recovery and wellness? / YES / NO

Employment/Volunteer Experience

The goal of the Certified Peer Specialist Employment Training is to prepare individuals (with a personal mental illness and/or dual diagnosis) who want to be employed as a staff in the mental health field, or related community programs. This is a job training certification. While employment upon graduation is not guaranteed, it is important that all applicants to CPS training are work-force ready to the best of his/her ability prior to attending the certification training.

Please answer the following questions about your vocational experiences:

1)Do you currently have a promise of employment with an organization upon successfully graduating from the CPS training? If so, please complete the information in the next box, including a signature from your potential supervisor.
(If you selected Yes, you do not need to answer any more questions in this section. Please continue to the section marked: Logistical Considerations). / Please check one of the follow responses:
___ Yes, I do have a promise of employment.
Employer: ______
Supervisor Name:______
Contact Info: ______
Potential first day of work: ______
Position to be held: ______
Employment Status: Full-time or Part-Time
Supervisor Signature/Date:
______
____ No, I do not have a promise of employment.
2)Do you have a resume that reflects your job history or vocational experiences? If so, please attach your resume to this application. If not, please answer questions #2, #3, and #4. / Please check one of the follow responses:
______Yes, I will be submitting my updated resume with this application.
_____ No, I will NOT be submitting a resume.
3)Do you currently hold a position (volunteer or paid) in which you empower others by sharing your recovery story and being a living example of recovery? / Please check one of the follow responses:
____ Yes, I do. I have worked at: (employer / year)
______
Start date: ______End date:______
____No, I do not.
4)Are you currently or have you been employed (paid or volunteer) within the last 12 months? / Please check one of the follow responses:
____ Yes, I have worked in the past 12 months.
Most recent Employer:______
Your title: ______
Dates of employment: (month/year)
Start date: ______End date:______
Your job responsibilities:
______
______
______
______
______
______
(for additional employment experiences please include on a resume)
____ No, I have NOT worked in the past 12
months.
5) Please select the following vocational experiences that you have. Please mark only areas of skills that you CURRENTLY feel comfortable utilizing for paid employment as a Certified Peer Specialist.
Select all that apply to you. / Vocational Areas of Skill Experience:
Email

Microsoft Word

Working on a PC

Working on a Mac

Using a basic cell phone
Using a Smart phone
Basic typing skills
Basic computer functioning and troubleshooting
Driving a vehicle (must have a current license)
6)Describe the areas would you like to strengthen for your professional development?
(For example: I would like to be more comfortable with public speaking). / Areas I would like to strengthen for my professional development:
7) Do you have additional post-high school/GED educational experiences?
(i.e. undergraduate/graduate degree, vocational training certifications, other certifications) / ____ Yes, I do. I will include my additional educational experiences on my resume or as an attachment to this application
_____ No, I do not.

Logistical Considerations

In order to ensure the best learning environment for our trainees, please answer the following questions:

1)Do you need Reasonable Accommodations for a disability during the training and/or graduation event? / Please check one of the follow responses:
____ Yes, I need Reasonable Accommodations. Please explain need:
____ No, I do NOT need Reasonable Accommodations.
2)Do you have any dietary restrictions and/or food allergies? / Please check one of the follow responses:
____ Yes, I do have dietary restrictions and/or food allergies. Please explain:
____ No, I do NOT have dietary or food allergy restrictions.
3)Are you able to make arrangements in your work and personal life to accommodate a 2 week (40 hours/week) training course?
(Consider: childcare, medical/health appointments, family or work commitments, travel restrictions, etc.) / Please check one of the follow responses:
___ Yes, I can make arrangements necessary.
___ No, I may have barriers to attending a 2 week training. Please explain:
4)Do you have access to a computer or a device with internet connection in order to utilize the Peers: Link to HOPE Initiative website? (Which will be live May 2016)
(
The website contains educational and interactive information for applicants, graduates and employers. / Please check one of the follow responses:
___ Yes, I do have access to a computer or a device with internet connection.
___ No, I do NOT have access to a computer or a device with internet connection.
5)To the best of your knowledge, are you able to pass a criminal background study to work with vulnerable adults?
(Your response may not affect your eligibility for the training, but could affect future employment opportunities as a CPS). / Please check one of the follow responses:
___ Yes, I should be able to pass a criminal background study.
___No, at this time I may not be able to pass a criminal background study. Please explain:
___ I do not know.

Recovery Bio

One of the fundamental requirements to being a Certified Peer Specialist comes from one’s personal experience of living with a mental illness and his/her ability to be far enough along in recovery and wellness to be able to help others in their recovery journeys.

Please all answer the following questions to help share your experience on the recovery path:

1)What is your understanding of the role of a Certified Peer Specialist (CPS)?

2)Why do you want to become a CPS? Please include personal qualities that you have that would make you effective in working with other people seeking wellness from mental illness.

3)What factors and persons were important and helpful for you in your recovery experience?

Additional Information/Attachments

Please include the following attachments to your application:

1)Two (2) letters of recommendation are required to be considered for training. Letters cannot be from a relative.

2)An updated, typed resume is strongly preferred but not mandatory.

3)Your responses to questions #1-3 under the Recovery Bio section. Responses are preferably typed--if handwritten, it must be legible.

4)Any educational transcripts (post-High School/GED) of academic experience that would support your role as a Certified Peer Specialist and/or reflect your skills strength to be a CPS trainee. (Submission of transcripts are not mandatory but recommended if available. Transcripts can be non-official copies).

5)Please sign and date application below.

Please make sure you have thoroughly answered and enclosed the necessary information for the application. Incomplete applications may delay process and prohibit acceptance into a training event.

Please keep a copy of your application for your records.

Once a completed application has been received, you will receive communication from the Peers: Link to HOPE Initiative Team within 30 days to set up a phone interview to go over your application as well as discuss potential training opportunities.

I, ______, submit my application to be considered for a Certified Peer Specialist Employment Training opportunity. The information I have submitted is an honest reflection of my experiences, my commitment to recovery, and my goal of becoming a Certified Peer Support Specialist. I understand that by submitting this application for training, it does not guarantee an opportunity to attend a training or employment as a Certified Peer Specialist.

Signature of Applicant:______Date:______

Thank you for completing your application for the Certified Peer Specialist

Employment Training!

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