Certified Youth Peer Support Training Application Form

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1. Contact Information (Required.)

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support. (Required.)

Yes

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3. County of Residence (Required.)

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4. Date of Birth (Required.)

MM/DD/YYYY

Date

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5. Please check the boxes that are applicable:

I believe individuals with mental health, addiction, and trauma experiences can embark on a recovery journey.

I believe there are multiple pathways to recovery for individuals with lived experience.

I am open and willing to appropriately share my story.

I need reasonable accommodations for the trainings. If yes, please share more information below.

Accommodations:

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6. I have personal lived experience with the following child-serving systems (please select all that apply):

Behavioral Health (Mental Health)

Behavioral Health (Addiction)

Juvenile Justice

Developmental Disabilities

Child Welfare

Education (IEP/504)

Certified Youth Peer Support Training Application Form

Question Title

1. Contact Information (Required.)

Question Title

2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support. (Required.)

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3. County of Residence (Required.)

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4. Date of Birth (Required.)

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5. Please check the boxes that are applicable:

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6. I have personal lived experience with the following child-serving systems (please select all that apply):

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7. Please share some brief information related to your wellness recovery journey. (Required.)

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8. Why are you interested in becoming a Certified Youth Peer Supporter? (Required.)

Certified Youth Peer Support Training Application Form

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* 1. Contact Information (Required.)

Question Title

* 2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support. (Required.)

Question Title

* 3. County of Residence (Required.)

Question Title

* 4. Date of Birth (Required.)

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* 5. Please check the boxes that are applicable:

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* 6. I have personal lived experience with the following child-serving systems (please select all that apply):

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* 7. Please share some brief information related to your wellness recovery journey. (Required.)

Question Title

* 8. Why are you interested in becoming a Certified Youth Peer Supporter? (Required.)

1. Contact Information (Required.)

2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support. (Required.)

3. County of Residence (Required.)

4. Date of Birth (Required.)

5. Please check the boxes that are applicable:

6. I have personal lived experience with the following child-serving systems (please select all that apply):

7. Please share some brief information related to your wellness recovery journey. (Required.)

8. Why are you interested in becoming a Certified Youth Peer Supporter? (Required.)