University of Pittsburgh



CONTINUING EDUCATION FOR VETERAN CERTIFIED PEER SPECIALISTS

Application for Participation

This regional 2-day training opportunity is intended for Certified Peer Specialists with priority given to veteran peer specialists. The fee for this 2 day session is $50.00.

Please indicate which 2-day training you are interested in attending:

|_____ Butler, PA |_____ Norristown, PA |_____ Scranton, PA |

|September 30, 2014 |October 29, 2014 |November 13, 2014 |

|October 1, 2014 |October 30, 2014 |November 14, 2014 |

|Government Center |Norristown State Hospital |Clarks Summit State Hospital. |

|124 West Diamond Street |Building #33 |1451 Hillside Dr # 1093 |

|Butler, PA 16001 |1001 Sterigere Street |Clarks Summit, PA 18411 |

| |Norristown, PA 19401 | |

| | | |

|Application Deadline: |Application Deadline: |Application Deadline: |

|September 15, 2014 |October 1, 2014 |Oct 15, 2014 |

Section 1: GENERAL PA Certified Peer Specialist (*CPS) INFORMATION

Name: ___________________________________________________________________________________________

Age: ______________________ Date of Birth: ______________________________________________

Address: _________________________________________________________________________________________

City, Zip-Code & County: ___________________________________________________________________________

Email: __________________________________________________________________________________________

Phone number(s): work____________________________ Home or Cell_________________________________

Current Employer or volunteer work:

Job title (if applicable):

Is this a CPS position: _____ Yes _____ No

Check the primary population you work with:

_______Veterans ________Forensics _______Transition Age Youth _______Adults over the age of 55

Have you completed the Forensic Continuing Education Training?

________Yes _________No

Did you serve in the military? _____ Yes _____ No

Current status: _____ Active _____ Reserve _____ Discharged (Date: __________________________)

Section 2: Required Prerequisite (Please answer the following questions.)

Are you a Certified Peer Specialist? _____ Yes _____ No

Date of certification: __________________________________ (Please attach a copy of your CPS Certificate)

Section 3: Interest and Involvement (Please briefly answer the following questions.)

1. Interest & Involvement:

A. Why do you want to work as a veteran/military peer support specialist?

B. What makes you a candidate to work with other Veterans in the behavioral (mental, co-occurring, forensic) health field?

C. What is your plan for involvement in local veteran initiatives and how do you see your work as a Peer after you receive the training?

2. Personal Recovery Experience:

A. What does recovery mean to you?

B. What were/are important factors in your own recovery?

C. What types of experiences have you had in assisting, or advocating for, Veterans or other people living with mental health issues (for example, support group leadership, WRAP, self-advocacy, programs you started, etc.)?

Section 4: Additional Important Information

1. Accommodation Request:

a. Do you need a specific accommodation to enhance your participation during the training (including linguistic needs, dietary restrictions, access, etc.)? If so, please be specific when listing them here. (Note: this has no bearing on the selection process.)

2. In case of an emergency: (Please list two people we can call if you have an emergency occur during the training):

1) Emergency Contact #1:

a. Name:

b. Relationship to you:

c. Phone number(s):

2) Emergency Contact #2:

a. Name:

b. Relationship to you:

c. Phone number(s):

Section 5: Submission

Please print your name, sign, and date.

Printed name: ____________________________________________________________

Signature: ___________________________________________________ Date: ________________

Please fax (717.772.7964), or mail to:

Ginny Mastrine | Human Services Program Specialist

Department of Public Welfare | OMHSAS

DGS Annex Complex

21 Beech Drive | 2nd floor Beechmont Building #32

Harrisburg PA 17110

Phone: 717.772.7926 | Fax: 717.772.7964

- IMPORTANT APPLICATION POINTERS-

Completed Application and CPS certification verification must be postmarked or faxed by COB on designated deadlines.

Late applications will not be considered.

If faxing your application, be sure to write your name at the top of each page and include a cover page to ensure that your entire application is kept together.

Specific information about building locations, parking, training times will be sent upon notification of acceptance for training.

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