APPLICATION FORM



The Role of Peer Specialists in Supporting Employment Goals

Advanced Training for Certified Peer Specialists*

*Funded through the National Association of State Mental Health Program Directors Employment Development Initiative

Classroom Training: December 12-13, 2012, DGS Annex (formerly Harrisburg State Hospital), Harrisburg, PA

This application will be used to select participants for pilot training programs for peer specialists and their supervisors. The pilot will test two new “advanced” CPS training curricula designed to provide currently employed peer specialists with the knowledge and skills needed to support the people they serve in pursuing their competitive employment goals. Applications will be accepted from agencies that offer peer support services and would like to have their peer specialists and supervisors attend the advanced training on employment.

• The first of the pilot training programs will be based on a two-day classroom training experience to be provided by the Institute on Recovery and Community Integration at the Mental Health Association of Southeastern Pennsylvania, dates and location to be determined.

• The second pilot program will be in an on-line format, which participants can connect to at a time that suits their personal schedules and will be offered by Recovery Opportunity Inc., and will need to be completed by a date to be determined (tentatively December 2012).

• Both curricula cover the same content.

Priority will be given to those peer specialists who participate in the training with their supervisor, and to multiple peer specialists and supervisors from agencies that have made a commitment to support the individuals they serve in pursuing competitive employment. To insure geographic and program diversity, no more than 3 peer specialists and 2 peer specialist supervisors will be approved from the same agency.

The training will be offered free of charge to trainees selected for the pilot. In addition, a stipend of up to $450.00 per person will be offered to participants in the classroom training pilot, to cover travel and related expenses; expenses incurred beyond the $450.00 limit will need to be covered by the training participant or his/her sponsoring agency. Although the maximum available stipend per person is $450, travel expenses (room, food, mileage) should not exceed the limits established by the federal agency Government Services Administration (GSA – ). To receive the reimbursement, trainees will need to submit receipts to Temple Collaborative on Community Inclusion of Individuals with Psychiatric Disabilities. Further information on travel expense reimbursement information will be disseminated to the trainees who are selected for the pilots. Applicants must indicate their preference for either classroom or online training in this application. Those selected will also be expected to participate in post training evaluations of their increase in knowledge and skills, as well as their perceptions of the value of the training program and how it might be improved.

Beginning in January of 2013, 1-hour biweekly “Community of Practice” conference calls will be held with all training graduates. The calls will focus on topics of interest to peer specialists and supervisors related to employment and education. These calls will also allow graduates to network with other peer specialists who are implementing the practices they learned in the training. Calls will continue through the end of the grant period-March 31, 2013.

The pilot advanced training program is supported by an Employment Development Initiative grant to the Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) from the National Association of State Mental Health Program Directors.

APPLICATION FOR PEER EMPLOYMENT TRAINING

NAME OF AGENCY APPLYING FOR THE TRAINING:______________________________________________________

ADDRESS: _____________________________________________________

_____________________________________________________

CITY, STATE, ZIP:_________________________ COUNTY:______________

AGENCY CONTACT PERSON/TITLE: ________________________________________________________________

PHONE: (work)_________________(Home or Cell) _____________________

E-MAIL:_________________________________________________________

Questions to be completed by the agency contact person:

(Please answer questions neatly and briefly in the space allowed or attach one (1) additional sheet)

1. Please describe the commitments your agency has made to emphasize employment goals and the current role of peer specialists in supporting those goals:

2. Briefly explain how your agency will use what the peer specialist(s) and peer specialist supervisor have learned from this training when they return to your agency:

3. Is your agency recommending that multiple peer specialists or peer specialist supervisors attend this training? If yes, list all proposed participants below. (Note that each peer specialist and peer supervisor must complete the relevant questions below, but applications can be submitted together for the entire agency. If a supervisor oversees more than one of the peer specialist applicants, he/she needs to complete the application only once).

4. Which training would you prefer that your staff attend? Note, if you are willing to have staff attend either, please note preference:

Two-day classroom training____

6-8 hour on-line training_____

If selected for the CPS Employment training, my agency agrees to:

1. Participate in follow up telephone interviews and questionnaires to help OMHSAS gather data and outcomes related to this pilot training.

2. Identify and support reasonable expenses beyond the $450.00/person stipend for expenses incurred for the peer specialist(s) and peer specialist supervisor directly related to classroom training.

3. Commit to having peer specialists and supervisors help individuals they work with to pursue their competitive employment goals.

Agency Representative Signature___________________________________

Title________________________________ Date__________________

Questions to be completed by each peer specialist supervisor

(Maximum 2 peer specialist supervisors/agency)

(Please answer questions briefly in the space allowed or attach one (1) additional sheet)

Name of peer specialist supervisor_____________________________________________________

Phone (work):_________________ Home or cell (optional):____________

Email (optional):________________________________________________

1. Briefly explain any experience you have had as a peer specialist supervisor in supporting a peer specialist’s focus on the employment goals of the people you serve:

2. How important is the goal of employment in the workplace where you supervise peer specialists?

3. How will you utilize the training experience to promote employment within the peer specialist program?

Questions to be completed by each peer specialist supervisor

(Maximum 2 peer specialist supervisors/agency)

(Please answer questions briefly in the space allowed or attach one (1) additional sheet)

Name of peer specialist supervisor_____________________________________________________

Phone (work):__________________ Home or cell (optional):___________

Email (optional):________________________________________________

1. Briefly explain any experience you have had as a peer specialist supervisor in supporting a peer specialist’s focus on the employment goals of the people you serve:

2. How important is the goal of employment in the workplace where you supervise peer specialists?

3. How will you utilize the training experience to promote employment within the peer specialist program?

Questions to be completed by each certified peer specialist

(Maximum 3 peer specialists/agency)

(Answer questions briefly in the space allowed or attach one (1) additional sheet)

Name of peer specialist _______________________________________

Phone (work):_________________ Home or cell (optional):__________

Email (optional):_____________________________________________

Number of years employed as a peer specialist__________

1. Why are you applying for the CPS employment

training?

2. What are you currently doing as a CPS to assist individuals with their employment goals?

3. What experience/training do you have in employment services for persons with mental illness?

4. If you are selected for the employment training what would you find helpful to learn about employment to assist peers in your current job?

Questions to be completed by each certified peer specialist

(Maximum 3 peer specialists/agency)

(Answer questions briefly in the space allowed or attach one (1) additional sheet)

Name of peer specialist _______________________________________

Phone (work):_________________ Home or cell (optional):__________

Email (optional):______________________________________________

Number of years employed as a peer specialist__________

1. Why are you applying for the CPS employment

training?

2. What are you currently doing as a CPS to assist individuals with their employment goals?

3. What experience/training do you have in employment services for persons with mental illness?

4. If you are selected for the employment training what would you find helpful to learn about employment to assist peers in your current job?

Questions to be completed by each certified peer specialist

(Maximum 3 peer specialists/agency)

(Answer questions briefly in the space allowed or attach one (1) additional sheet)

Name of peer specialist _______________________________________

Phone (work):_________________ Home or cell (optional):__________

Email (optional):______________________________________________

Number of years employed as a peer specialist__________

1. Why are you applying for the CPS employment

training?

2. What are you currently doing as a CPS to assist individuals with their employment goals?

3. What experience/training do you have in employment services for persons with mental illness?

4. If you are selected for the employment training what would you find helpful to learn about employment to assist peers in your current job?

Deadline for applications to be received:

Thursday, November 8, 2012

PLEASE ATTACH:

1) COPY OF EACH PEER SPECIALIST’S TRAINING CERTIFICATE

2) QUESTIONNAIRE FOR THE AGENCY, EACH PEER SPECIALIST SUPERVISOR AND EACH PEER SPECIALIST

3) SIGNATURE PAGE

MAIL or FAX TO:

Angela Roland, EDI, Grant Project Coordinator

OMHSAS

Room 207, Beechmont Building

DGS Annex Complex

21 Beech Drive

Harrisburg, PA 17110

Fax: 717-772-7964

APPLICATION MUST BE RECEIVED BY OMHSAS NO LATER THAN NOVEMBER 8, 2012.

OR SCAN and EMAIL APPLICATION TO:

aroland@

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