Medi-Cal Peer Support Specialist Training Interest Form

This interest form is to let NAMI California know that you are interested in completing the Medi-Cal Peer Support Specialist Training. Please answer the following questions.

If you have any questions while completing this form or after, please contact Ragini Lal, Ragini@namica.org.

Question Title

* 1. Please provide the following contact information:

First Name *

Last Name *

Personal Email *

Work Email (if applicable)

City *

County *

ZIP/Postal Code *

Personal Phone Number *

Work Phone Number (if applicable)

Question Title

* 2. I acknowledge that I will be taking this training virtually.

Yes

Question Title

* 3. I understand that this training includes a total 80 hours of Medi-Cal Peer Support Specialist training (70 hours of live online training and 10 hours of homework, examination preparation, and attendance in office hours).

Yes

Question Title

* 4. I understand after completion of this 80- hour course, it will be my responsibility to apply to sit for the Medi-Cal Peer Certification Exam.

Yes

Question Title

* 5. I can confirm that I meet the following requirements:
I am at least 18 years of age
I possess a high school diploma or equivalent degree
I self-identify as having experience with the process of recovery from mental illness or substance use disorder, either as a consumer of these services or as a the parent, caregiver, or family member of a consumer
I am willing to share my experience
I have a strong dedication to recovery

Yes

Question Title

* 6. Are you currently Employed or Volunteer in the peer workforce?

Yes

Question Title

* 7. If yes, please share the following information:

Name of Organization

Position Title

Hours Per Week (Work or Volunteer)

Date Started (MM/YYYY)

Duties

Supervisor's Name

Supervisor's Email

Supervisor's Phone Number

Question Title

* 8. I acknowledge that I am completing an interest form and that I will be contacted if I qualify to participate in the Medi-Cal Peer Support Specialist Training.

Yes