Peer Support Employment Training Application

Peer Support Employment Training Application Form

If you have one of the following AHCCCS insurance plans, the cost of the course will be covered by your insurance: United Healthcare, Health Choice, Mercy Care, Banner University Family Care, AIHP, and Molina. If you do not have one of the listed plans, the out-of-pocket cost for the course is $600.00.

"*" indicates required fields

Select Desired Course*

Today's Date:*

MM slash DD slash YYYY

Name of Applicant:*

Date of Birth:

MM slash DD slash YYYY

Email Address:*

Phone Number:*

Insurance Provider*

Would You Benefit from a Scholarship?*

Yes

Current Address*

Street City State ZIP / Postal Code Country

Emergency Contact Information

Emergency Contact*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Please refer to AHCCCS Policy 963 Attachment B for the Peer Support Employment Training Template referenced below:

A. Pre-Screening:

Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?

Yes

Do you understand that the completion of a Peer Support Employment Training program is not a guarantee of employment?

Yes

Self-identification as a person with lived experiences of behavioral health conditions is a requirement to receive a PRSS credential. Upon completion of this program your name, the name of the training program, date of graduation and current employer (if applicable) will be transmitted to AHCCCS as specified in AMPM Policy 963, Attachment C. This is not considered health information and evidence of a credential may be shared with potential employers and others without a release of information. Please mark yes to attest that you understand and agree to this.

Yes

B. Purpose of Training

1. Please describe when and why you have decided to become a Peer Recovery Support Specialist?

My employer is requiring me to take this course

I want to begin applying for employment in the behavioral health/substance abuse field

Other

2. What are you looking forward to most about this training?

Gaining knowledge and skills to work in the behavioral health/substance use field

Learning how to use my recovery to help others

Other

3. A PRSS often spends a lot of time doing paperwork and may have other duties unrelated to practicing and delivering peer support services. Would that be a problem?

Yes

4. Do you have any concerns about working in environments that you may feel are less Recovery-Oriented and less- welcoming?

Yes

C. Self-Identification:

"I willingly self-identify to others as having lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and life disruption, for which I have sought some type of help or care."

Yes

"I am actively engaged in my own recovery, healing, and wellness practices."

Yes

"I am willing to share these lived experiences, when appropriate, for purposes of education, role modeling and providing hope to others about the reality of recovery."

Yes

Personal Recovery:

Are you willing to share what you have had to overcome to get where you are today?

Yes

Are you willing to share what having “lived experience” means to you? Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

Yes

D. Commitment to Training Participation and Accommodation:

This training program requires complete attendance for the duration of the training. If accepted to the program, can you commit to the attendance requirement?

Yes

Are there any barriers which may keep you from attending the entire training (e.g., childcare, work schedule, transportation)?

Yes

The training is highly interactive and requires activities involving small group work, role-playing, and reading aloud to the class. Are you comfortable with this kind of participation?

Yes

As part of the training, you will be asked to participate in discussions, role-plays, and to share your personal story of recovery in front of the class. Are you comfortable with this kind of participation?

Yes

Are there any accessibility needs for you to fully participate in the training? (e.g., service animal, note taker, large text, sign language interpreter)?

Yes

During the training you will listen to the recovery stories of others. Sometimes these stories may be uncomfortable to hear. Are you willing to communicate any discomfort to the trainers if this were to happen?

Yes

E. Attestations:

Please check to attest you understand and agree to the below statements:*

I understand that a PRSS Credential is not health information and is necessary for employment and delivering services as a PRSS. Evidence of my credential may be shared with potential employers and others without a release of information.

Please check to attest you understand and agree to the below statements:*

I understand that Scottsdale Recovery Center requires 45 days of continuous sobriety to register for and begin peer support employment training. I understand that I must maintain my sobriety for the duration of the course.*

Please check to attest you understand and agree to the below statements:*

I understand that I will be required to take a competency exam at the end of the training, and I must receive a passing score of 80% or more to receive my peer credentials. If I do not receive a passing grade, I may apply to take the exam over 1 time. If I do not receive a passing score the 2nd time, I may be required to take/review specific portions based on trainer discretion. Failure to receive a passing score after retesting the 3rd time will result in taking the course again prior to retesting (or further accommodations may be made at the discretion of the trainer).*

Please check to attest you understand and agree to the below statements:*

I have answered the questions in this application truthfully, and to the best of my ability.*

Digital Signature*

Date*

MM slash DD slash YYYY

88672

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Peer Support Employment
Training Application