SP 23 Peer Recovery Support Specialist Certification Application

Participant Information

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* 1. Contact Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Personal Email Address

Phone Number

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* 2. Date of birth

MM/DD/YYYY Format

Date

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* 3. Are you a veteran of the U.S. Armed Forces?

Yes

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* 4. Are you a US citizen or are you authorized to work in the United States?

Yes

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* 5. What is your race?

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Prefer not to answer

None of the above

Some other race (please specify)

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* 6. Are you of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin

Yes, I am of Hispanic, Latino or Spanish origin

Prefer not to answer

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* 7. What is your Gender Identity?

Male

Female

Transgender

Nonbinary

Prefer not to answer

Other (please specify)

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* 8. Are you or will you be the first person in your family to receive a college degree (Parents, grandparents, siblings do not have a college degree)?

Yes

Not applicable

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* 9. Do you have lived experience with mental health disorders (self or family member)?

Yes

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* 10. Do you have lived experience with substance abuse disorders (self or family member)?

Yes

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* 11. Are you currently in recovery?

No, I am not yet in recovery

No I am not in recovery, my personal experience is with a family member

Yes (Please specify how long)

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* 12. Are you currently employed?

Yes, employed full-time

Yes, employed part-time

No, currently not employed

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* 13. What is the highest grade or level of school you have completed or highest degree you have received?

Middle School or Junior High graduate

High School diploma or GED

Some College, No Degree

Vocational/Technical Degree

Associate Degree

Bachelor Degree

Masters Degree

PhD or beyond

None of these

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* 14. Do you hold any Certifications or Licensures?

Yes (please specify)

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* 15. Do you have a valid Drivers License?

Yes

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* 16. Please list any additional cities or towns you lived in before you turned 18? Please include the state if not in Illinois.

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