Family Peer Support Specialist Application

1. Family Peer Specialist Application

Thank you for your interest in becoming a Family Peer Support Specialist (FPSS) in the Commonwealth of Pennsylvania. This is a new program, and we are seeking individuals that represent the diversity and county specific geography of Pennsylvania, and that have direct experience as a parent/caregiver for a family member with mental health challenges to work with parents and families that are struggling. To do this, we are offering a five-day training divided into three segments (2-day training, 2-day training, and 1-day training). Information about the training logistics (dates, locations and times, etc.) will be provided if you are selected as an FPSS candidate. A training Certificate of Completion will be issued to accepted participants upon successful completion of the Family Peer training. Board certification (currently not available) will require additional requirements in addition to this training to become PA Certified as a Family Peer Support Specialist. The first step is to complete and submit this application. This information is confidential and will be shared only with the program coordinator, trainer or identified person in the selection process. This information is only for use in the selection process, for trainers knowledge and data collecting purposes. At no time will it be shared outside of the persons identified above. Your name and personal information will not be identifiable while using for data collection.

This is a competitive process, and class sizes are limited. Individuals that meet the selection criteria are eligible, and those that are selected will be notified by the coordinator with additional information. Unfortunately, not all applicants will be selected. Acceptance and completion of the Family Peer training does guarantee employment.

You will receive confirmation of receipt of your application. If you do not or have any questions, please contact the Family Peer Support Specialist Program Coordinator, Jill Santiago, at santiagoj@upmc.edu.

Thank you again for your interest and time.

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* 1. Contact Information

Name *

Address *

City/Town *

State/Province *

ZIP/Postal Code *

County *

Email Address

Phone Number *

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* 2. What is the date and name of the training that you are interested in attending? Example: Family Peer Support Specialist Training on 6/19/20 in Philadelphia. Please put the place of the training.

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* 3. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 4. Highest Education Level. Please note that HS diploma, GED or equivalent from another country is required for training and eventual certification as an FPS.

High School Graduate/GED

Some College

College Graduate with Associate's Degree

College Graduate with Bachelor's Degree

College Graduate with Master's Degree or Higher

No Formal Education

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* 5. Do you identify as an active duty member, veteran, spouse, or
dependent of the U.S. Armed Forces, Reserves, or
National Guard?

Yes, active duty

Yes, veteran

Yes, retired military

Yes, dependent spouse

Yes, current military dependent

Please list branch and years of service

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* 6. Race

African American or Black

American Indian

Alaska Native

Native Haiwaiian or other Pacific Islander

Asian

White

Other (please specify)

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* 7. Ethnicity

Hispanic or Latino

Central American

Cuban

Dominican

Mexican

Puerto Rican

South American

Non Hispanic or Latino

Other (please specify)

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* 8. How do you describe your gender identity?

Female

Male

Other

Other gender identity (please specify)

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* 9. What is your marital status? Please select one from the list below.

Single

Single, never married

Married

Domestic Partner

Widowed

Divorced

Separated

I prefer not to answer

Other (please specify)

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* 10. What is the income of your household?

Below 10K

10K to 25K

25K to 50K

50K to 75K

75K to 100K

Over a 100K

I prefer not to answer

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* 11. Does employer require or support your attendance at this training?

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* 12. Please list applicable employment history for the past 5 years
(Employer, Position, Dates of employment). Please feel free to upload your resume instead of a written response. If you prefer a written response please see question #10.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 13. Please provide your Supervisors information below. If none just type NONE in the Name box.

Name *

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 14. Please use the box below if you did not upload a resume in order to provide your employment history. Please indicate in the box below if you submitted a resume.

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* 15. Please list any volunteer work, committees, and/or informal work you have been involved in over the last 5 years. Examples include Task Force, Educational, PTA, Scouts, Faith-based. That is relevant to this opportunity. (Include Location, Position Title, Duties, and Dates).

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* 16. Please list any specific skills, trainings, or certifications you have received. Please include any advocacy trainings you have attended. Examples include, Active Listening, Family Support Partner, Trauma Informed, Family Group Decision Making Facilitator, Certified Peer Specialist,Mental Health First Aid, High Fidelity Wraparound, Strenghting Families, CPR.

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* 17. Please list any leadership experience you have had at a local, county, state or national level. Examples include County Leadership Teams, Advisory or Governance boards, Scout Leader, PTA/PTO board. If not applicable, please respond with none.

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* 18. Please check all of the systems/supports your family member currently has or have been involved with:

Children's Behavioral Health

Juvenile Justice System

Children and Youth Services

Adult Behavioral Health Services

Adult Probation/Parole

Criminal Justice System

Child/Youth Drug and Alcohol Services

Adult Drug and Alcohol Services

Developmental Disability

Physical Health ie. chronic health conditions or special health care needs

Education (IEP, 504 Plan, GIEP, Alternative Schools etc)

Psychiatric Hospitalizations

Residential Treatment Facility

Group Homes

Other (please specify)

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* 19. Please describe what services and supports are currently in place or have been used/received in the past by the child(of any age), youth or young adult for whom you are the primary caregiver.

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* 20. When was your most current experience/s with services or formal supports for the family member that you are the primary support/caregiver for? Please indicate by checking the box below that applies.

1-3 years

3-5 years

5-10 years

or more than 10 years

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* 21. As the primary caregiver I am considered as a/an _____________________ to the individual(s).

Immediate Family Member with legal and fincial responisbility for the person (Parent, Legal Guardian, Step-Parent, Adoptive Parent, Siblings)

Extended Family Member (Grandparent, Aunt, Uncle, Cousin)

Foster Family or Kinship Family Member

Identified Family Member (People chosen by the individual receiving services - Examples friend, boy/girlfriend, neighbor, etc)

I do not consider myself to be a family member.

Other (please specify)

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* 22. What are/have your responsibilities been as the primary caregiver?

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* 23. What diagnosis does your family member currently have? Please select all the apply.

Attention-deficit/hyperactivity Disorder

Alcohol/Substance Disorder

Anxiety Disorder

Attachment Disorder

Autism Spectrum Disorders

Bi-Polar Disorder/Major Depressive Episode. Hypomanic Episode. Manic Episode. Mixed Specifier
(Formerly Mixed Episode)

Behavioral challenges

Depression

Eating Disorders

Fetal Alcohol Spectrum Disorder

Intellectual Developmental Disability

Obsessive-compulsive Disorder

Personality Disorders

Post Traumatic Stress Disorder (PTSD)

Psychosis

Schizophrenia

Self harm

Suicidal Ideation

Trauma related disorders

Other (please specify)

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* 24. Is English your primary language?

Yes

If the answer is no (please specify) what other language/s you speak.

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* 25. Please tell us what you believe the role of a Family Peer Support Specialist is and why you are interested in becoming one? Please answer in a minimum of a 100 words and no more than 250 words.

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* 26. Explain how your lived experiences (positive and negative) has fostered your personal growth. Please answer in a minimum of a 100 words and no more than 250 words.

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* 27. What makes you an excellent candidate to work with caregivers as a Family Peer Specialist? Please answer in a minimum of a 100 words and no more than 250 words.

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* 28. Briefly describe the most valuable assistance or support you have received as a parent or caregiver. Please answer in a minimum of a 100 words and no more than 250 words.

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* 29. My family member(s) first became involved with the systems listed above at the age(s) of:

0-5 years old

6-12 years old

13-17 years old

18-26 years old

27-29 years old

30-39 years old

40-49 years old

50-59 years old

60-69 years old

70 and older

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* 30. What is the current age of the person you are or have been the primary caregiver?

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* 31. You will receive training and coaching on story sharing as part of this training. Would you be comfortable and willing to share your story?

Yes

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* 32. Describe how you practice stress reduction to manage the stress of supporting a family member with mental health or substance use disorders.

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* 33. A personal or professional letter of recommendation is required. Please either email your letter to Jill Santiago at santiagoj@upmc.edu or upload your letter when submitting your application. If you require assistance or have a question please email Jill Santiago at the email address above.

Please upload your document here.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* 1. Contact Information

Question Title

* 2. What is the date and name of the training that you are interested in attending? Example: Family Peer Support Specialist Training on 6/19/20 in Philadelphia. Please put the place of the training.

Question Title

* 3. In what year were you born? (enter 4-digit birth year; for example, 1976)

Question Title

* 4. Highest Education Level. Please note that HS diploma, GED or equivalent from another country is required for training and eventual certification as an FPS.

Question Title

* 5. Do you identify as an active duty member, veteran, spouse, or dependent of the U.S. Armed Forces, Reserves, or National Guard?

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* 6. Race

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* 7. Ethnicity

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* 8. How do you describe your gender identity?

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* 9. What is your marital status? Please select one from the list below.

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* 10. What is the income of your household?

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* 11. Does employer require or support your attendance at this training?

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* 12. Please list applicable employment history for the past 5 years (Employer, Position, Dates of employment). Please feel free to upload your resume instead of a written response. If you prefer a written response please see question #10.

Question Title

* 13. Please provide your Supervisors information below. If none just type NONE in the Name box.

Question Title

* 14. Please use the box below if you did not upload a resume in order to provide your employment history. Please indicate in the box below if you submitted a resume.

Question Title

* 15. Please list any volunteer work, committees, and/or informal work you have been involved in over the last 5 years. Examples include Task Force, Educational, PTA, Scouts, Faith-based. That is relevant to this opportunity. (Include Location, Position Title, Duties, and Dates).

Question Title

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* 17. Please list any leadership experience you have had at a local, county, state or national level. Examples include County Leadership Teams, Advisory or Governance boards, Scout Leader, PTA/PTO board. If not applicable, please respond with none.

Question Title

* 18. Please check all of the systems/supports your family member currently has or have been involved with:

Question Title

* 19. Please describe what services and supports are currently in place or have been used/received in the past by the child(of any age), youth or young adult for whom you are the primary caregiver.

Question Title

* 20. When was your most current experience/s with services or formal supports for the family member that you are the primary support/caregiver for? Please indicate by checking the box below that applies.

Question Title

* 21. As the primary caregiver I am considered as a/an _____________________ to the individual(s).

Question Title

* 22. What are/have your responsibilities been as the primary caregiver?

Question Title

* 23. What diagnosis does your family member currently have? Please select all the apply.

Question Title

* 24. Is English your primary language?

Question Title

* 25. Please tell us what you believe the role of a Family Peer Support Specialist is and why you are interested in becoming one? Please answer in a minimum of a 100 words and no more than 250 words.

Question Title

* 26. Explain how your lived experiences (positive and negative) has fostered your personal growth. Please answer in a minimum of a 100 words and no more than 250 words.

Question Title

* 27. What makes you an excellent candidate to work with caregivers as a Family Peer Specialist? Please answer in a minimum of a 100 words and no more than 250 words.

Question Title

* 28. Briefly describe the most valuable assistance or support you have received as a parent or caregiver. Please answer in a minimum of a 100 words and no more than 250 words.

Question Title

* 29. My family member(s) first became involved with the systems listed above at the age(s) of:

Question Title

* 30. What is the current age of the person you are or have been the primary caregiver?

Question Title

* 31. You will receive training and coaching on story sharing as part of this training. Would you be comfortable and willing to share your story?

Question Title

* 32. Describe how you practice stress reduction to manage the stress of supporting a family member with mental health or substance use disorders.

Question Title

* 33. A personal or professional letter of recommendation is required. Please either email your letter to Jill Santiago at santiagoj@upmc.edu or upload your letter when submitting your application. If you require assistance or have a question please email Jill Santiago at the email address above.

* 5. Do you identify as an active duty member, veteran, spouse, or
dependent of the U.S. Armed Forces, Reserves, or
National Guard?

* 12. Please list applicable employment history for the past 5 years
(Employer, Position, Dates of employment). Please feel free to upload your resume instead of a written response. If you prefer a written response please see question #10.