Pre-Registration Form for Medi-Cal Peer Support Specialist Certification Training 2024

To pre-register, you must complete each response

Please note that the pre-registration will not be complete unless all questions are fully answered. Thank you! The training is 20 days (four weeks), M-F, 8:30 am- 12:30 pm. Participants may not miss more than 8 hours total. Please note that the pre-registration is not a guarantee of enrollment. After individuals pre-register and we get about three weeks out from the start date of the training, you will start receiving requests for your response. Only those who are responsive in a timely manner will be enrolled. Those who are not responsive or are late in their response may be wait listed for a future class.

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* 1. What is your full name?

First Name

Last Name

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* 2. Choose your training dates (please note that the class size is limited to 14 participants in order to keep the learning experiential and supportive. There is a chance that you may be waitlisted for a given date selection. You will be notified as soon as practicable if you will be waitlisted. We encourage you to be responsive to emails from us in order to maintain the order of your training request.)

January 8 through February 5, 2024 (THIS TRAINING COHORT IS FULL. Please select a different date)

January 29 through February 26, 2024 (THIS TRAINING COHORT IS FULL. Please select a different date)

February 26 through March 22, 2024

March 25 through April 19, 2024

April 22 through May 17, 2024

May 20 through June 14, 2024

June 17 through July 16, 2024

July 15 through August 9, 2024

August 12 through September 9, 2024

September 9 through October 4, 2024

September 30 through October 25, 2024

October 28 through November 22, 2024

November 25 through December 23, 2024

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* 3. What is the best phone number to contact you?

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* 4. What is your email address?

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* 5. In a few words, please describe your interest in this training program.

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* 6. Participating in this training program requires you to have a lived recovery experience defined as personal experience of being a consumer of mental health or substance use disorder services, or as a parent, family member or direct care supporter of someone who does. Do you have a lived recovery experience, as defined here?

Yes

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* 7. Do you have a CalMHSA scholarship?

Yes

I have applied and its pending

I do not know.

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* 8. What is your employment or volunteer status?

Yes. I am employed part time (20 hours or less per week).

Yes. I am employed full time (36-40 hours per week).

Yes. I am an unpaid volunteer

No. I am unemployed and I do not currently volunteer.

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* 9. What is the title of your employment/volunteer position?

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* 10. What is the name of your employer & program or volunteer placement site?

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* 11. Name of the county you live in. Please DO NOT put "CA" or "California" as a response. This will invalidate your pre-registration. Please identify the county you live in and/or work in.