Thank you for your interest in the Passaic CPRS Training class. To be considered, please complete the application form. Upon submission, a brief interview will be scheduled as the next step in the selection process.

Please note that all applications related to Prevention is Key's CPRS Training are confidential. Your responses will be de-identified before being shared with Prevention is Key staff and the funding agency to ensure your privacy. If you have any questions about the application or any of its contents, please contact Laura Werner at lwerner@mcpik.org.

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* 1. First and Last Name:

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* 2. Address

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* 4. Contact Info

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* 5. What do you consider yourself to be?

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* 6. What is your race? 

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* 7. What County do you live in?

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* 8. Do you work in Passaic County? If so, where?

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* 9. What is the highest degree you have received? (Select one):

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* 10. Relationship Status:

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* 11. Veteran Status

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* 12. Employment Status:

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* 13. Do you currently have a stable place to live?

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* 14. What type of housing do you live in? (i.e., own, rent, shelter, etc.):

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* 15. How did you find out about our CPRS training?

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* 16. Referred by:

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* 17. Do you consider yourself to be a person in recovery?

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* 18. Do you consider yourself to have "lived experience" with another person's substance use and/or recovery (i.e., friend/family member/client)?

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* 19. Have you ever been to substance use or mental health treatment?

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* 20. Do you have personal experience with criminal justice and/or social services?

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* 21. Are you currently on probation or parole?

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* 22. Do you have a support network?

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* 23. Do you enjoy being supportive of others in their recovery?

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* 24. How satisfied are you with your personal relationships?

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* 25. Rate your Physical Health

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* 26. Rate your Mental Health

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* 27. Have you ever attended/participated in recovery support groups (12-step, SMART, etc.)?

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* 28. What Does Recovery Mean to You?

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* 29. Can you commit to having a private space & stable internet connection to attend all class sessions (Tues. & Thurs. 9-12pm)?

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* 30. How comfortable are you sharing your own lived experience in general terms with drugs & alcohol with others?

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* 31. Do you think someone must stop all drug use to be in "recovery"?

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* 32. Are you willing and able to connect with strangers quickly?

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* 33. Can you work with someone currently using drugs?

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