Certified Peer Counselor Training Application - Wa



Certified Peer Counselor Training ApplicationThis application intends to measure your readiness and skills to be an effective Certified Peer Counselor. You must answer all questions on this application in order for the Health Care Authority to review and accept your submission. Certification RequirementsYou must self-identify as a person with lived experience with mental health or substance use services or be a parent or legal guardian of a child with lived experience with mental health or substance use services. You must demonstrate reading and writing comprehension.Application ProcessComplete this application without assistance. To request accommodations or alternative formats, call at 360-725-plete the required online course and submit your completion certificate with this application.By mail: DBHR Peer Support Program, PO Box 42730, Olympia, WA 98504-5330By email: peersupportapps@hca.By fax: 360-725-1385Scoring ConsiderationsConsider the following as you complete your application.Applicants receive a higher score when they:Describe more work or volunteer experiences.Have specific employment plans or goals to work at a behavioral health agency or other organization as peer counselor.Demonstrate a strong understanding of recovery concepts.Show a genuine desire to assist others and high level of comfort sharing their personal experiences.Priority is given to:Applicants currently working as a peer counselor at a behavioral health agency or who have a confirmed job offer.Applicants volunteering at a behavioral health agency, currently working as a peer counselor or recovery coach at a peer run organization or who have a confirmed peer related job offer.Applicants who are U.S. Veterans. Additional ConsiderationsConsider the following before going through this application process.What does it mean to be in recovery?This is a question you should ask yourself carefully. No one but you can say whether or not you are in recovery. Being a Certified Peer Counselor means being able to help others and work regularly. If you are a parent or guardian, responding to recovery questions could include skills you have gained in promoting your child’s recovery and resilience. In your responses, strive to demonstrate:Your understanding of recovery and resiliency principles.Skills you have learned to maintain your recovery.What you have learned from your experience that you would like to share with others.How do I demonstrate leadership skills?Leadership can take many forms. You may have formal leadership experience from participating in local committees or boards, or facilitating or teaching groups or classes. If participating in groups or classes has helped you develop leadership skills, please write about that, including any experiences you feel have allowed you to develop your leadership skills.How much information do I share about my personal story?Strive to convey your comfort level in sharing your story. What kinds of experiences do you have sharing your story? How long have been sharing your story? Are you just learning to be comfortable sharing your story? Please do not share the details of your story in this application. We do not need specific information about hospitalizations, medications or therapy.Thank you for applying for the Certified Peer Counselor training and best wishes on your journey!Application for Peer Counselor TrainingPlease type or print clearly. All sections must be completed for the application to be accepted.The information you provide in this application will be shared with the Division of Behavioral Health and Recovery’s (DBHR) designated contractor for training and other DBHR approved training entities.The Washington State Health Care Authority provides equal opportunity for all applicants regardless of race, color, creed, religion, national origin, sexual orientation, veteran status, gender, disability status or age.Desired Training(s)Location: FORMTEXT ?????Dates: FORMTEXT ?????Location: FORMTEXT ?????Dates: FORMTEXT ?????1 Applicant InformationLast NameFirstM. I. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???Mailing AddressCityStateZIP Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CountyDaytime TelephoneCell PhoneEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Education FORMCHECKBOX High school diploma or GED FORMCHECKBOX Additional Education: FORMTEXT ?????Are you over 18? FORMCHECKBOX Yes FORMCHECKBOX NoPlease list any languages (other than English) in which you are fluent: FORMTEXT ?????Race (Optional) (Check any that apply) FORMCHECKBOX African American FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Asian / Pacific Islander FORMCHECKBOX Caucasian FORMCHECKBOX Hispanic FORMCHECKBOX Other: FORMTEXT ?????2 EligibilityTo qualify for this training, you must have significant experience in recovery. I agree I meet this definition as a: (Check all that apply) FORMCHECKBOX A person who is receiving or who has received mental health services. FORMCHECKBOX A person who is receiving or who has received substance use treatment services. FORMCHECKBOX A parent, legal guardian, or primary caretaker of a child who is receiving or who has received behavioral health services (mental health or substance use treatment services). Please describe how you meet the eligibility standards above for significant lived experience with behavioral health recovery (mental health, or substance use treatment): FORMTEXT ?????3 EmploymentI am currently: FORMCHECKBOX employed FORMCHECKBOX volunteering FORMCHECKBOX providing peer support or recovery coachingAgency or place of employment or volunteer workProgram FORMTEXT ????? FORMTEXT ?????Position titleContact phone number FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX I am a WISe team member.The following questions are scored by DBHR. Please answer each question carefully, using good writing skills and detailed answers.Briefly describe your current job duties or your activities as an employee or volunteer. Include the length of time you have worked in this position. FORMTEXT ?????This training is intended to prepare you to work as a certified peer counselor in a Medicaid Behavioral Health Agency. What are your employment goals? FORMTEXT ?????4 Additional Questions for Peer Counselor TrainingSuccessful applicants will demonstrate that they:Have been well-grounded in their own recovery for at least one year.Have qualities of leadership, including experience with advocacy, creation, implementation or facilitation of peer-to-peer groups or activities.Please answer the following questions to demonstrate that you meet the above requirements for successful applicants.Your answers may be typed or handwritten. Attach a separate sheet of paper if additional space is needed. Why are you interested in becoming a Certified Peer Counselor? FORMTEXT ?????Applicants must be well grounded in their own recovery for at least one year. This question is individual to each person, but should indicate an understanding of the principles of recovery. Have you or your family been in recovery for at least one year? Describe how you know you are in recovery and how you stay in recovery. FORMTEXT ?????Without sharing the details of your recovery story, explain how you have shared your personal recovery story to assist others. Include examples of your leadership qualities. (Certified Peer Counselors are expected to share their recovery stories with peers as part of their job duties when they’re employed.) FORMTEXT ?????5 SignatureBy signing and submitting this form I affirm the following:I have completed this application myself with no assistance and understand that this is a test of my reading comprehension and writing skills.I understand:training slots are limited and therefore submission of this application does not guarantee admission. after completing the required online course and required CPC classroom training, I must also successfully pass an oral and a written exam to qualify for certification by the Division of Behavioral Health and Recovery.certification as a Peer Counselor does not guarantee employment.in most cases, in order to be employed I must meet Department of Health requirements and obtain an Agency Affiliated Counselor registration.a criminal justice background may in some cases prevent licensure or employment with a DSHS licensed agency.SIGNATUREDATE FORMTEXT ?????Unless otherwise indicated, upon certification your name will be included in the DBHR email distribution lists to communicate current job opportunities and other information specific to peer counseling. FORMCHECKBOX Please do not include my email on lists related to peer counseling and employment.Additional information about Peer Support can be found at hca.billers-providers-partners/behavioral-health-recovery/peer-support.Please mail or email your application to:DBHR Peer Support Program PO Box 42705 Olympia, WA 98504-2705FAX: 360-725-1385peersupportapps@hca.This application must be sent with the online course completion certificate or it will not be accepted. The online course may be found at peer-initiatives.For questions regarding the Peer Support Program please contact the peer support team at peersupportprogram@hca. or 360-725-1325. ................
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