Peer Support Employment Training Application

Peer Support Employment Training Application Form

If you have ACCHCS insurance, the cost of the course will be covered by ACCHCS. When filling out the application, please include a copy of your ACCHCS insurance card and your ACCHCS ID number. If you do not have ACCHCS insurance, the cost of the course is $300.00.

"*" indicates required fields

Course:*

5 week Friday class: this course meets every Friday from 8am-4pm for 5 weeks. Next Friday course starts May 10th.

10 week Thursday evening class: this course meets every Thursday from 5:30pm-9:30pm for 10 weeks. Next Thursday course starts May 2nd.

Today's Date:*

MM slash DD slash YYYY

Name of Applicant:*

Date of Birth:

MM slash DD slash YYYY

Email Address:*

Phone Number:*

Copy of ID

Max. file size: 50 MB.

Do you have AHCCCS (UHC, Health Choice, Mercy Care, or AIHP)?*

Yes

AHCCCS ID:

Copy of front and back of AHCCCS card

Max. file size: 50 MB.

Current Address

Street City State ZIP / Postal Code Country

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

Program Providing Peer Support Employment Training: Scottsdale Recovery Center

A. Pre-Screening:

Completing and submitting this application does not guarantee admission into a Peer Support Employment Training Program (PSETP). Scottsdale Recovery Center may have other requirements such as assessments, referrals, additional forms and/or tuition which must be completed or paid prior to start of the Employment Training program. Please contact Nathan Gossen ([email protected]) Scottsdale Recovery Center to determine eligibility for training.

Please answer the following to the best of your knowledge.

Are you attending this program as an employee of Scottsdale Recovery Center because you have lived experience being impacted by substance use and/or mental health and plan to deliver services as a peer or other behavioral health professional?

Yes

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

Yes

Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?
*Please check skip if you are currently an employee of Scottsdale Recovery Center.

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

Yes

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

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

*Most employers require their new hires to have a High School Diploma or General Education Development (GED). Read the following and check the box that is true for you:*

I have a High School Diploma or GED.

I am in the process of obtaining a High School Diploma or GED.

I do not have, but would like to obtain, a High School Diploma or GED.

I do not have, nor am I interested in obtaining, a High School Diploma or GED.

B. Purpose of Training:

This training is intended to prepare you to practice and deliver peer support services in the AHCCCS (Medicaid) programs. Please describe when and why you have decided to become a Peer Recovery Support Specialist? If you are a Scottsdale Recovery Center employee please enter your position and any credentials you hold below.

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

2. What concerns, if any, do you have about Peer Support Employment Training?

3. Some work environments may seem more recovery-oriented and more welcoming than others. What concerns, if any, do you have about working in environments that you may feel are less Recovery-Oriented and less- welcoming?

C. Self-Identification:

A Peer and Recovery Support Specialist (PRSS) is an individual who has lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and life disruption, for which they have sought help or care; and can demonstrate their own efforts at self-directed recovery and expertise, including knowledge of approaches to support the recovery of others.

Read the following statements and tell us if they are true or not true, for you.

"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,
this is true for me.

No,
this is not true for me.

"I am actively sustaining my own recovery and/or healing process; and managing my own wellness."

Yes,
this is true for me.

No,
this is not true for me.

"I am actively sustaining my own recovery and/or healing process; and managing my own wellness."

"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,
this is true for me.

No,
this is not true for me.

"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."

Personal Recovery:

The following Yes/No questions relate to how you practice your own recovery. Answering "YES" to any of the following questions means that you are willing to share your response at a later date. You will NOT be asked to share your response at this time.

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

Yes

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

Are you willing to share what has helped you to move from where you were to where you are now in your recovery?

Yes

Are you willing to share what has helped you to move from where you were to where you are now in your recovery?

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

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?

Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

Yes

Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

D. Commitment to Training Participation and Accommodation:

The training program may require complete attendance for the duration of the training. If accepted to this program, can you commit to this?

Yes

The training program may require complete attendance for the duration of the training. If accepted to this program, can you commit to this?

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

Yes

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

If yes, please describe:

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

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?

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. What concerns, if any, would you have about this?

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

If any of the above is challenging to you, how do you think you will approach it?

Yes

If any of the above is challenging to you, how do you think you will approach it?

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

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

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 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.*

Printed Name*

Digital Signature*

Date*

MM slash DD slash YYYY

66995

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Peer Support Employment
Training Application

Peer Support Employment Training Application Form