APPLICATION FOR TRAINING LOUISIANA PEER SUPPORT SPECIALIST APPLICATION FOR TRAINING LOUISIANA PEER SUPPORT SPECIALIST Application Date MM slash DD slash YYYY Part I – Contact InformationName First Last Mailing Address (Cannot be a P.O. Box) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhonePrimary Email Secondary Email Part II – Education & TrainingWhat is your highest level of education?(Required) High School Diploma G. E. D. Some College Associate Bachelor’s Master’s Doctorate Name of Schools (hit the + sign to add more) Add RemovePLEASE UPLOAD A COPY OF HIGHEST DIPLOMA, DEGREE, AND/OR TRANSCRIPTMax. file size: 50 MB.Certificate and LicensesTypeNumberIssuing Agency Add RemovePart III – Demographic Information (for statistical purposes only)Race / Ethnicity African American Latino/Hispanic Multiracial Native American Asian American Caucasian Other If Other, What Race/Ethnicity? Foreign Languages Spoken Spanish French Vietnamese ASL Other If Other, What Foreign Language Do You Speak? Gender Male Female Trans Female (MTF/Male to Female) Trans Male (FTM/Female to Male) Gender Non-Conforming (i.e. not exclusively Male or Female) Prefer not to disclose Prefer to self-describe Self-describe in the box below: Date of Birth MM slash DD slash YYYY Part IV – Supplemental Information Have you ever served in the Military? Yes No Do you have experience working with any special populations or groups? Veterans Homeless Addictions Trauma Families Physical Health Intellectual/Development Disabilities Youth Others Describe what strengths and skills you may bring to a Peer Support positions. Please also describe what skills you need to develop.Part V – Recovery Statement Briefly describe your lived experience with behavioral health challenges (mental health and/or substance use) and your personal recovery journey, including the date your recovery began.Part VI – PLEASE READ THE FOLLOWING QUESTIONS CAREFULLY BEFORE ANSWERING. 1. What is your personal definition of recovery? What factors are important in your own recovery?2. Please describe what Peer Support means to you:3. Why do you want to become a Peer Support Specialist?4. Do you think that it is important to share recovery stories as part of being a Peer Support Specialist? Why?5. What is your plan to deal with triggers and/or recurrence of your symptoms?6. Please describe the ways you have been active in your community in the past six months. Please highlight roles that would aid in your work as a Peer Support Specialist.7. One key to recovery is the use of natural supports in your life. Please describe your support system and how they can help you if you are selected for the Peer Support Training?8. An important aspect of the Peer Specialist Training program is that everyone must be personally responsible for their actions and decisions. Please describe personal responsibility and how you will incorporate it into your work as a Peer Support Specialist:9. What are some of the things you do on a regular basis to keep yourself focused on your recovery?10. What type of activities or other interest do you enjoy during your free time?Part VII – Current & Previous Employment/Volunteer Experience A. Are you currently employed as a Peer Support Specialist? Yes No – See B and C below What is your job title? Name of Employer? How many hours do you work a week? What is your hourly wage? How long have you been employed in this position? Employers Contact Information B. If no, are you looking for work as a PSS? Yes No C. If no, are you currently working in another capacity? Yes No What is your job title? May we contact your employer? Yes No Name of your employer? Employer’s Contact Information Please list your other work experience for the past five years beginning with your most recent job held previous to the one listed in C above. If you were self-employed, provide business name. (Add additional work by hitting the + )Employer of Volunteer AgencyPosition/TitleLocation Add RemovePlease list 3 professional and personal references (not related to you):(Add additional work by hitting the + )NameTelephone Number Add RemoveWhich training dates are you interested in? First Choice Date Second Choice Date Name First Last Providers or sponsoring organizations that are not LDH state operated organizations, which includes LGEs and state operated hospitals, will be expected to submit a $500 registration for their Peers to attend the training. This payment must be submitted prior to training, to The Extra Mile, Region IV, who is contracted to arrange Peer Support employment trainings for the Office of Behavioral Health. You will be contacted by them to arrange payment. There are a limited number of scholarships available for those with demonstrated needs. Please contact George Mills at [email protected] or 337-237-2090 for more information on how to apply. Please check box if you’re interested in a scholarship application. I am interested.Please provide the following information: I confirm my employer is aware of my application for the Peer Support Specialist Training. My employer has approved my attendance and confirmed the registration will be paid.I certify that this information is correct. All information provided is correct.Date MM slash DD slash YYYY Name First Last
