Peer Specialist Certified

Application for March **** Certified Peer Specialist (CPS) Two Week Certification Training Program

*Applications accepted from January 24 – February 11,2022. All applications and

required documentation must be completed by applicant and received by

email (******.***********@*****.***)

Emergency Contact Information:

Name: Relationship: Phone #:

Current Lives With Self Family Member Recovery/Half-way House My housing is unstable

Other

Have you participated in any DBHIDS system transformation efforts (i.e. Storytelling Training, Narcan Training,

MH First Aid)?

Yes, my certificates are attached, and I have attended: No

*NOTE: THE QUALIFICATIONS DESCRIBED IN THE NEXT THREE SECTIONS ARE SET BY THE STATE OF PENNSYLVANIA AND ARE MANDATED REQUIREMENTS FOR TRAINING AS A CERTIFIED PEER SPECIALIST FUNDED BY HEALTH CHOICES.

QUALIFICATIONS FOR TRAINING

No later than 12pm on February 11, 2022

** INCOMPLETE OR LATE APPLICATIONS WILL NOT BE PROCESSED**

Demographic Information:

Legal Preferred Date of

Name: Name Birth:

MM/DD/YEAR

Street Address: Apt: Philadelphia, PA Zip

Home #: Cell #: Email:

GENDER:

Male Female Transgender/Gender Variant

CULTURAL IDENTIFICATION (Optional) Check All that Apply:

Asian African American Continental African/African Caribbean Caucasian Latino/Hispanic

Native American/Pacific Islander Other

1.)BEHAVIORAL HEALTH INFORMATION :

I personally identify as someone who is a present or past recipient of mental health services for a Serious

Mental Illness

OR

I personally identify as someone who is a present or past recipient of mental health services for a Serious Mental

Illness AND substance use challenge

***Please provide verification of your past or present mental health treatment

(for example: copy of behavioral health evaluation, letter from clinician, discharge plan)

Lived experience of Substance Use Treatment only is not sufficient to meet the requirement for CPS Training

2.)EDUCATIONAL INFORMATION:

Name of School/Educational Program:

Highest Grade Completed: Certificate Diploma GED College Trade Graduation Date

***Submission of a copy of your high school or college diploma or proof of GED is required. ***

Have you received services from the Office of Vocational Rehabilitation (OVR) within the past 3 years? Yes No

Are you a Veteran of the United States Armed Forces? Yes No

Do you receive SSI and/or SSDI benefits? Yes No

3)Employment/Income Information: ***Verification of employment activity from Employer and a Current Resume are required and must be attached on letterhead to application. ***

Please list any paid or volunteer work experience that you have maintained in the last 3 years for 12 months OR any earned post-secondary education credits totaling 24 credits (need not be consecutive).

Where Position Date: From To Supervisor Name Telephone Number Was it Paid or Volunteer How Many Hours a week

Where Position Date: From To Supervisor Name Telephone Number Was it Paid or Volunteer How Many Hours a week

Where Position Date: From To Supervisor Name Telephone Number Was it Paid or Volunteer How Many Hours a week

ADDITIONAL DOCUMENTATION REQUIRED ***Please submit the following***

Philadelphia residency verification Professional letter of recommendation on letterhead

TRANSPORTATION

Do you rely on Public Transportation? Yes No If no, what is your means of transportation?

Do you have a valid PA Driver’s License? Yes No

The following questions will assist the review committee with the selection from many applicants. Please answer each question to the best of your knowledge as thoroughly as you can.

1.What does recovery mean to you? What wellness tools are important in your own recovery?

2.Peer specialists are models of recovery for others. In what ways do you demonstrate your recovery goal of a full and meaningful life in the community? Please provide detail about activities and interests.

3.Peer Specialists are required to complete documentation on the job. Describe your computer knowledge and skills.

AGREEMENT

The Certified Peer Specialist Certification Training Program is a 10-day training scholarship opportunity. You must be present and actively participate in order to complete the training and receive the CPS certificate. In order to receive the certification, trainees are required to attend the training for the entire 10 days of certification. Trainees are required to be present on and participate in all the scheduled days and to possess a cumulative score between 140-200 points (includes attendance, punctuality, participation, and 2 knowledge-based exams and the Pennsylvania Certification Board exam scheduled some weeks later). You must pass the PCB exam for certification. Applicants are applying for the March training. You will be notified if you are invited to interview.

Trainees will receive an additional certificate for the Wellness Recovery Action Plan (WRAP), which is covered for two days during the training. Full attendance on both days is required. The certificate can be used to register for the 5-day WRAP Facilitators’ certification training, which is offered in the City of Philadelphia through DBHIDS.

This training involves both lectures and group activities. The group activities are a place in which respect and support are very important. The trainers will utilize two tests, class participation, involvement in group activity and general attendance to assess readiness to provide behavioral health services in a professional setting. In addition to providing education to trainees, there will be skill building through role play, take home activities and sharing personal experiences of recovery from mental health challenges. Integrity is essential to this position. If it is deemed that you are conducting yourself in an unethical way at any time during the application, interviews or training, you will be asked to halt the training process.

Interviews will be scheduled by telephone with the CPS Planning team for a limited number of applicants March 14th through 18th, 2022. If you are selected, you will be notified which day and time you will be invited to interview by telephone. In addition, there may be a virtual orientation March 21, 2021 at 10:00am before the class.

Each trainee is responsible for adjusting his/her schedule in order to attend the entire 10 days of training.

This training is not open to individuals in special detention programs, e.g. work release, house arrest, etc.

Certification does not guarantee employment. While we anticipate that there will be many positions opening for Certified Peer Specialists in residential, day programs, case management and other behavior health programs in the upcoming months, this certification is not a guarantee for employment. You are responsible for applying for CPS positions for which you qualify in the system; however, we will assist you in identifying positions for which you qualify and in which you may be interested. We will also assist those who complete the training with continuing their education.

By signing below I acknowledge that I meet, understand and agree to all terms of this program; and that the responses to all questions on the application are my own.

Signature of Applicant: Date:

PLEASE SUBMIT BY EMAIL YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENTS TO:

******.***********@*****.***

For questions, please send an email to ******.***********@*****.***

Applications must be received by 12pm on March 11,2022

(Please note that DBHIDS does not make copies of submitted documents)

Applicants not contacted for interviews will be notified about application status within 60 days from the date of application closing. Applicants have 45 days from the date of above notifications to review results.

PEER CULTURE AND

COMMUNITY INCLUSION UNIT

Model, Inspire, and Inform”

DBHIDS CPS Application Checklist

Check all of the boxes and attach this document to your application. Thank you!

1. March 2022 CPS Application

2. Proof of Education (Copy of High School Diploma, GED or official college transcript)

3. Proof of Philadelphia County Residency (State ID, Utility Bill)

4. Proof of Mental Health/Co-Occurring Diagnosis (Psychiatric or Psychological

Evaluation, Discharge Summary, Letter from current clinician on letterhead)

5. Proof of Work or Volunteer Experience: (Letter written by a former or present

employer, teacher, or volunteer supervisor to verify 12 months’ work or volunteer activity within the last 3 years on letter head stating hours worked and tasks performed)

6. Professional Resume

7. Current Letter of Recommendation on Letterhead (Written by a former or present

employer, teacher or volunteer supervisor)

8. Story-Telling Training certificate attached

For DBHIDS PCCI Use Only:

Applicant Name: Application Complete: Yes No

1st Review By: (initials) Date:

Notes:

2nd Review By: (initials) Date:

Notes:

Application Score:

Final Score:

Approval Date:

Interview Date:

** INCOMPLETE OR LATE APPLICATIONS WILL NOT BE PROCESSED**

Contact this candidate