Application for Training Louisiana Peer Support Specialist

APPLICATION FOR TRAINING LOUISIANA PEER SUPPORT SPECIALIST

Application Date

MM slash DD slash YYYY

Part I – Contact Information

Name

First Last

Mailing Address (Cannot be a P.O. Box)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Primary Email

Secondary Email

Part II – Education & Training

What is your highest level of education?(Required)

High School Diploma

G. E. D.

Some College

Associate

Bachelor’s

Master’s

Doctorate

Name of Schools (hit the + sign to add more)

PLEASE UPLOAD A COPY OF HIGHEST DIPLOMA, DEGREE, AND/OR TRANSCRIPT

Max. file size: 50 MB.

Certificate and Licenses

Type

Number

Issuing Agency

Part III – Demographic Information (for statistical purposes only)

Race / Ethnicity

African American

Latino/Hispanic

Multiracial

Native American

Asian American

Caucasian

Other

If Other, What Race/Ethnicity?

Foreign Languages Spoken

Spanish

French

Vietnamese

ASL

Other

If Other, What Foreign Language Do You Speak?

Gender

Male

Female

Trans Female (MTF/Male to Female)

Trans Male (FTM/Female to Male)

Gender Non-Conforming (i.e. not exclusively Male or Female)

Prefer not to disclose

Prefer to self-describe

Self-describe in the box below:

Date of Birth

MM slash DD slash YYYY

Part IV – Supplemental Information

Have you ever served in the Military?

Yes

Do you have experience working with any special populations or groups?

Veterans

Homeless

Addictions

Trauma

Families

Physical Health

Intellectual/Development Disabilities

Youth

Others

Describe what strengths and skills you may bring to a Peer Support positions. Please also describe what skills you need to develop.

Part V – Recovery Statement

Briefly describe your lived experience with behavioral health challenges (mental health and/or substance use) and your personal recovery journey, including the date your recovery began.

Part VI – PLEASE READ THE FOLLOWING QUESTIONS CAREFULLY BEFORE ANSWERING.

1. What is your personal definition of recovery? What factors are important in your own recovery?

2. Please describe what Peer Support means to you:

3. Why do you want to become a Peer Support Specialist?

4. Do you think that it is important to share recovery stories as part of being a Peer Support Specialist? Why?

5. What is your plan to deal with triggers and/or recurrence of your symptoms?

6. Please describe the ways you have been active in your community in the past six months. Please highlight roles that would aid in your work as a Peer Support Specialist.

7. One key to recovery is the use of natural supports in your life. Please describe your support system and how they can help you if you are selected for the Peer Support Training?

8. An important aspect of the Peer Specialist Training program is that everyone must be personally responsible for their actions and decisions. Please describe personal responsibility and how you will incorporate it into your work as a Peer Support Specialist:

9. What are some of the things you do on a regular basis to keep yourself focused on your recovery?

10. What type of activities or other interest do you enjoy during your free time?

Part VII – Current & Previous Employment/Volunteer Experience

A. Are you currently employed as a Peer Support Specialist?

Yes

No – See B and C below

What is your job title?

Name of Employer?

How many hours do you work a week?

What is your hourly wage?

How long have you been employed in this position?

Employers Contact Information

B. If no, are you looking for work as a PSS?

Yes

C. If no, are you currently working in another capacity?

Yes

What is your job title?

May we contact your employer?

Yes

Name of your employer?

Employer’s Contact Information

Please list your other work experience for the past five years beginning with your most recent job held previous to the one listed in C above. If you were self-employed, provide business name. (Add additional work by hitting the + )

Employer of Volunteer Agency

Position/Title

Location

Please list 3 professional and personal references (not related to you):(Add additional work by hitting the + )

Name

Telephone Number

Which training dates are you interested in?

First Choice Date

Second Choice Date

Name

First Last

Providers or sponsoring organizations that are not LDH state operated organizations, which includes LGEs and state operated hospitals, will be expected to submit a $500 registration for their Peers to attend the training. This payment must be submitted prior to training, to The Extra Mile, Region IV, who is contracted to arrange Peer Support employment trainings for the Office of Behavioral Health. You will be contacted by them to arrange payment. There are a limited number of scholarships available for those with demonstrated needs. Please contact George Mills at [email protected] or 337-237-2090 for more information on how to apply.

Please check box if you’re interested in a scholarship application.

I am interested.

Please provide the following information:
I confirm my employer is aware of my application for the Peer Support Specialist Training. My employer has approved my attendance and confirmed the registration will be paid.

I certify that this information is correct.

All information provided is correct.

Date

MM slash DD slash YYYY

Name

First Last

APPLICATION FOR TRAINING LOUISIANA PEER SUPPORT SPECIALIST

APPLICATION FOR TRAINING LOUISIANA PEER SUPPORT SPECIALIST

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