Pre-Registration Form for CMPSS Specialization: Parent, Caregiver, Family Member Peer

To fully register, you must complete each response

Please note that the registration will not be complete unless all questions are fully answered. We cannot guarantee your enrollment by completing this pre-registration. You will be placed in an order of priority, based on the number of individuals who both pre-register and who complete the full registration when requested to do so. Some individuals may likely be waitlisted and or requested to pre-register for a later date. Thank you for your patience.

Please note that there is a $500 tuition fee for this course. You will need to make payment arrangements once your enrollment in the course is confirmed. We do not offer scholarships for this course.

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1. What is your full name? (Required.)

First Name

Last Name

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2. This training course is for Certified Peer Support Specialist only. You must have state certification to participate. Are you a certified peer support specialist? (Required.)

Yes

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3. Please provide your state certification number:

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4. Choose your training dates. Please note that the class size is limited to 14 participants in order to keep the learning experiential and supportive. Also, please check back for updated schedules, as more and more people seek this specialization. The tuition cost to take the training is $500 per participant. (Required.)

March 22 through April 2, 2027

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5. What is the best phone number to contact you? (Required.)

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6. What is your email address? (Required.)

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7. In a few words, please describe your interest in this training program. (Required.)

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8. 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? (Required.)

Yes

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9. What is your employment or volunteer status? (Required.)

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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10. What is the title of your employment/volunteer position? (Required.)

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11. Is your employment with any of the following? Please check all that apply:

Behavioral Health County Agency

Community Based Organization (CBO)

Peer Run Organization

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12. What age range applies to you?

Between the ages of 18 - 25

Between the ages of 26 - 64

65+

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13. Gender Identity

Male

Female

Non-Binary

Prefer not to answer

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14. Race/Ethnicity

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

Pre-Registration Form for CMPSS Specialization: Parent, Caregiver, Family Member Peer

To fully register, you must complete each response

Question Title

1. What is your full name? (Required.)

Question Title

2. This training course is for Certified Peer Support Specialist only. You must have state certification to participate. Are you a certified peer support specialist? (Required.)

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3. Please provide your state certification number:

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5. What is the best phone number to contact you? (Required.)

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6. What is your email address? (Required.)

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7. In a few words, please describe your interest in this training program. (Required.)

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9. What is your employment or volunteer status? (Required.)

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10. What is the title of your employment/volunteer position? (Required.)

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11. Is your employment with any of the following? Please check all that apply:

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12. What age range applies to you?

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13. Gender Identity

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14. Race/Ethnicity

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15. Do you speak any other language(s) other than English? If so, please list them here:

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16. Name of your county (Required.)

Pre-Registration Form for CMPSS Specialization: Parent, Caregiver, Family Member Peer

To fully register, you must complete each response

Question Title

* 1. What is your full name? (Required.)

Question Title

* 2. This training course is for Certified Peer Support Specialist only. You must have state certification to participate. Are you a certified peer support specialist? (Required.)

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* 3. Please provide your state certification number:

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* 5. What is the best phone number to contact you? (Required.)

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* 6. What is your email address? (Required.)

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* 7. In a few words, please describe your interest in this training program. (Required.)

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* 9. What is your employment or volunteer status? (Required.)

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* 10. What is the title of your employment/volunteer position? (Required.)

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* 11. Is your employment with any of the following? Please check all that apply:

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* 12. What age range applies to you?

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* 13. Gender Identity

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* 14. Race/Ethnicity

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* 15. Do you speak any other language(s) other than English? If so, please list them here:

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* 16. Name of your county (Required.)

1. What is your full name? (Required.)

2. This training course is for Certified Peer Support Specialist only. You must have state certification to participate. Are you a certified peer support specialist? (Required.)

3. Please provide your state certification number:

5. What is the best phone number to contact you? (Required.)

6. What is your email address? (Required.)

7. In a few words, please describe your interest in this training program. (Required.)

9. What is your employment or volunteer status? (Required.)

10. What is the title of your employment/volunteer position? (Required.)

11. Is your employment with any of the following? Please check all that apply:

12. What age range applies to you?

13. Gender Identity

14. Race/Ethnicity

15. Do you speak any other language(s) other than English? If so, please list them here:

16. Name of your county (Required.)