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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. 
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:
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.)
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.)
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.)
9.What is your employment or volunteer status?(Required.)
10.What is the title of your employment/volunteer position?(Required.)
11.What is the name of your employer & program or volunteer placement site?(Required.)
12.Name of your county(Required.)