APPLICATION FOR TRAINING LOUISIANA RECOGNIZED FAMILY PEER SUPPORT SPECIALIST (RFPSS) APPLICATION FOR TRAINING LOUISIANA RECOGNIZED FAMILY PEER SUPPORT SPECIALIST (RFPSS) 2.9.24 Application Date(Required) MM slash DD slash YYYY Part I – Contact InformationName(Required) First Last Mailing Address (Cannot be a P.O. Box)(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Primary Email(Required) Secondary Email Part II – Education & Training PLEASE EMAIL A COPY OF HIGHEST DIPLOMA, DEGREE, AND/OR TRANSCRIPT TO [email protected]What 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) *optional*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?(Required) Yes No Do you have experience working with any special populations or groups?(Required) 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 – Lived Experience Statement Briefly describe your experience with being a Parent or Caregiver of a child with complex needs inclusive of social, emotional, mental health, and/or substance use concerns, and/or involvement with child welfare or juvenile justice systems.Part VI – PLEASE READ THE FOLLOWING QUESTIONS CAREFULLY BEFORE ANSWERING. 1. What is your personal definition of wellness? What factors are important in your own recovery?(Required)2. Please describe what Family Peer Support means to you:(Required)3. Why do you want to become a Family Peer Support Specialist?(Required)4. Do you think that it is important to share stories of your past experiences as part of being a Family Peer Support Specialist? Why?(Required)5. 5. What is your plan to deal with your own personal triggers while advocating for others?(Required)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 Family Peer Support Specialist.(Required)7. 7. Please describe your self-care plan and how they can help you if you are selected for the Family Peer Support Training?(Required)8. 8. An important aspect of the Family Peer Specialist Training program is establishing clear boundaries with families. Please describe what your actions would be if you suspect the boundary lines are being crossed:(Required)9. 9. What type of activities or other interest do you enjoy during your free time?(Required)Part VII – Current & Previous Employment/Volunteer Experience A. Are you currently employed as a Family Peer Support Specialist?(Required) 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 FPSS? Yes No C. If no, are you currently working in another capacity? Yes No What is your job title? Name of your employer? May we contact your employer? Yes No 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 RemoveI certify that I have given true, accurate, and complete information on this form to the best of my knowledge. I certify that I am at least 24 years of age and have a minimum of one year demonstrated continuous and/or current lived experience with a child with mental and/or behavioral health challenges before applying for certification. I understand that any false information or omissions may be grounds for rejection of my application or corrective action. I certify that I have only acted in ways which did not abuse, neglect or exploit any consumer or family member situation in my role as a Peer Support Specialist.Name(Required) First Last Date(Required) MM slash DD slash YYYY If you are currently employed as a Family Peer Support Specialist, or your participation is being sponsored, you must have your employer or sponsoring agency complete the following form: 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 Family 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 employers who are not LDH state operated organizations. Please contact George Mills at [email protected] or (office) 337-237-2090 (cell) 225-290-7598 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 Family Peer Support Specialist Training. My employer has approved my attendance and confirmed the registration will be paid. I am aware that my employer must submit the Employer Attestation Form for my application to be considered complete.(Required) All information provided is correct.I certify that this information is correct.(Required) All information provided is correct.Date(Required) MM slash DD slash YYYY Name(Required) First Last
