*1.Name(Required.)

*2.Organizations's name(Required.)

*3.What state does your program operate in?(Required.)

AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of Columbia (DC)FloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

*4.Is your state currently actively certifying family/parent peers?(Required.)

No

Yes

*5.Does your state require certification for family/parent peer support providers?  If yes, what organization/entity provides certification?(Required.)

No

Yes (please specify organization/entity)

*6.Does your state offer family/parent peer support as a Medicaid reimbursable service?(Required.)

No

Yes

*7.What types of funding other than Medicaid is available for family/parent peers?(Required.)

*8.Does your state currently accept national certification in lieu of state certification?(Required.)

No

Yes

9.Is being a parent/caregiver of a child
with behavioral health challenges a
requirement to be a family/parent
support provider?

Yes - Lived experience as a caregiver of a child with behavioral health    challeges is required

No - Lived Experience is not required

10.Please send the Core Compentencies used by your state to Mcovington@ffcmh.org or insert link below

11.Please send a copy of the job description you use for Family/Parent    Support Providers to Mcovington@ffcmh.org

12.Who is the designated person for your agency to work with the Federation on
this project?

Name

Email

Phone