Enrollment Application for
Medi-Cal Peer Support Specialist Certification Training

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* 1. Are you a California (CA) resident?

Yes

No

If no, list your state of residency

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* 2. Name the CA County you live in:

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* 3. Age:

16 or Under

17

18-25

26-64

65+

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* 4. Do you have at least a GED, High School Diploma, or advanced degree?

Yes

No

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* 5. Do you identify as an individual with "lived experience" (someone who has received services for a mental/substance use disorder/behavioral health issue or are a family member or caregiver who has assisted someone with these services) and are dedicated to helping people recover from similar experiences?

Yes

No

25% of survey complete.