Pre-Registration Form for MC PSSC Specialization: Parent, Caregiver, Family Member

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.

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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. Also, please check back for updated schedules, as more and more people seek this specialization.

Online Training: October 9-20, 8:30am-12:30pm (M-F) (40 hours) (THIS COHORT IS NOW FULL- Please pre-register for a later date)

Online Training: November 6 through November 20, 2023, 8:30am-12:30pm (M-F) (40 hours)

Online Training: November 27 through December 8, 2023, 8:30am-12:30pm (M-F) (40 hours)

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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? If you do not have a scholarship, we recommend that you apply at: https://www.capeercertification.org/certification-scholarships/

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.

Pre-Registration Form for MC PSSC Specialization: Parent, Caregiver, Family Member

To fully register, you must complete each response

Question Title

* 1. What is your full name?

Question Title

* 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. Also, please check back for updated schedules, as more and more people seek this specialization.

Question Title

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

Question Title

* 4. What is your email address?

Question Title

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

Question Title

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* 7. Do you have a CalMHSA scholarship? If you do not have a scholarship, we recommend that you apply at: https://www.capeercertification.org/certification-scholarships/

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* 8. What is your employment or volunteer status?

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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 your county