Certified Youth Peer Support Training Application Form Survey

1.Contact Information(Required.)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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

No

3.County of Residence(Required.)

4.Date of Birth(Required.)

MM/DD/YYYY

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

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:

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.)