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 do not guarantee employment.

You will receive confirmation of receipt of your application within 72 hours. 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

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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 6/19/18 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.

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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? 

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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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* 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.

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* 13. 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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* 14. 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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* 15. 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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* 16. 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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* 17. Please check all of the systems/supports your family member currently has or have been involved with:

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* 18. 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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* 19. 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.

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

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

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

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* 23. Is English your primary language?

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* 24. 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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* 25. 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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* 26. 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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* 27. 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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* 28. My family member(s) first became involved with the systems listed above at the age(s) of:

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

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

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* 31. 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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* 32. 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.

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