Mental Health Peer Work Champions Initiative

Champions Package 2 Application Form ONLY

When completed please scan and email to: Simona Adochiei ;

or fax this form to 02 9810 8145; or post to PO Box 668 Rozelle NSW 2039.

For further information email or phone Simona on 02 9555 8388 x 106

Applicant’s Personal Details

Surname:
Given Names:
Home Address:
State: / Postcode: / Male / Female / Other
Tel (H): / Tel (W):
Tel (M): / Fax:
Email:
Date of Birth:
Employer: / Position title:
Length of time in position: / Please circle F/ T or P/T
Please tick ü that you have read and understood the Champion Package 2 Handbook for Cert IV MHPW Only before completing this application.
Please tick ü relevant areas:
I am applying as a consumer peer worker
I am applying as carer peer worker
I am Aboriginal, Torres Strait Islander or Aboriginal and Torres Strait Islander
I am from a culturally or linguistically diverse background where English is not my first language
I am from an Australian regional or remote area
I plan to provide the Cert IV in Mental Health Peer Work training in the following area/s
NSW / VIC / TAS / WA / ACT / SA / QLD / NT

Applicant Selection Criteria Checklist


To be selected for the Champions Package 2 – Cert IV MHPW Only applicants must meet all the selection criteria. Please tick ü to confirm you meet the following selection criteria before proceeding.

1.  I have provided support in a peer to peer capacity eg consumer peer worker providing support to consumers OR a carer peer worker providing support to carers. (If your position is different to this please enquire with MHCC)
2.  I have 3 to 5 years’ experience working in an identified consumer or carer peer worker role (paid/unpaid) providing direct ongoing support to individuals as part of my day to day work. Minimum experience is 3 days/week for 3 years. Experience must include time within the last 2 years.
3.  I am able to demonstrate a minimum of 2 years substantial experience as a trainer/facilitator (minimum of 50 days in the last 3 years). This could include group training, group facilitation and facilitating support groups (this does not include delivering a presentation).
4.  I am able to work with a Registered Training Organisation (RTO) in my area to deliver the Cert IV Mental Health Peer Work qualification. I can provide name and contact details for any RTOs I plan to work with, describe how I will work with them and attach evidence of any discussions I have had.
5.  I am able and ready to study at a Cert IV level and attend the 5 day skills recognition program in either February or April 2015 for Cert IV MHPW and have completed the Cert IV MHPW Recognition Self-Assessment Tool.
6.  I have not previously started or completed the Cert IV in MHPW (CHC42912).
7.  I am able to provide evidence that I am currently enrolled in or have completed the Cert IV in Training and Assessment (TAE40110).
References
I am providing the details of two referees who have observed me and agreed to provide endorsement of my skills, knowledge and experience in:
Direct Peer Work
Referee name: Position/title:
Organisation: Email: Phone:
Group facilitation and training
Referee name: Position/title:
Organisation: Email: Phone:
Applicant Signature: / Date:

Applicant signature required – a typed name will not be accepted

Applicant Selection Criteria - Written Component

The following section is part of the selection criteria and must be filled out. Application forms sent in without this information will not be assessed.

a) Please list all the peer work positions you have held; including their year/s, duration and the name of the organisation. For example:
Peer Support Worker - 2013 – 2014 - 1 year, 15 hours a week, ABC organisation.
Peer work position / Duration / Organisation
b) Please list all the training and facilitation experience you have had including, duration and the name of the organisation. For example:
Trainer - 2013 – 2014 - 1 year, 15 hours a week, ABC organisation.
Training/facilitation role / Duration / Organisation
c) What is your understanding of the role of a peer worker? (150 words)
d) What are the values or principles that underpin peer work? (150 words)
e) How is your work recovery oriented? (150 words)
f) What is your understanding of effective group facilitation and provide one example of how you have applied this in your work (150 words).
g) Describe your readiness to study at Cert IV level and complete the TAE and MHPW training within the timeframes outlined for Package 3. Describe any previous study and the support network that may assist you to complete the qualification.
(200 words)
h) Describe the importance of reflective practice for your role as a peer worker?
(150 words)
i) Provide details of RTO/s in your area that you are able to work with to deliver the Cert IV Mental Health Peer Work qualification. Please include name and contact details for these RTOs, describe how you will work with them and attach any evidence of any discussions you have had.

Application Checklist

Before sending in your application, ensure that your supporting information is attached and the form is fully completed, and tick ü below to show:

I have read and understood the Champion Package 2 Handbook for Cert IV MHPW Only

I have completed the Cert IV MHPW Recognition Self-Assessment Tool

I have completed the Applicant Selection criteria checklist

I have completed the Applicant Selection criteria – Written Component

I have attached a certified copy of my certificate or evidence of enrolment in the Cert IV in TAE (TAE40110)

(A certified copy is a copy signed by an approved witness such as JP, pharmacist, doctor. For a full list go to: http://www.ag.gov.au/Publications/Pages/Statutorydeclarationsignatorylist.aspx)

I have attached evidence of any discussions I had with RTOs in my area in order to work with them to deliver the Cert IV in MHPW

I have provided contact details of a referee for training and facilitation experience

I have provided contact details of a referee for direct peer work experience

I have signed and dated below

Consent and Signature of the Applicant

In completing and signing this form you:

·  Consent to MHCC collecting personal information related to the assessment of eligibility for Champion Package 2

·  Agree that the information you have provided is true and complete

Signature: / Date:

Applicant signature required – a typed name will not be accepted

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MHCC Champions of Mental Health Peer Work Pilot Initiative - Application Form 2014 – Package 2