Medi-Cal Peer Support Specialist Training Interest Form

This interest form is to let NAMI California know that you are interested in completing the Medi-Cal Peer Support Specialist Training. Please answer the following questions.

If you have any questions while completing this form or after, please contact Ragini Lal, Ragini@namica.org.

*1.Please provide the following contact information:(Required.)

First Name *

Last Name *

Personal Email *

Work Email (if applicable)

City *

County *

ZIP/Postal Code *

Personal Phone Number *

Work Phone Number (if applicable)

*2.I acknowledge that I will be taking this training virtually.(Required.)

Yes

*3.I understand that this training includes a total 80 hours of Medi-Cal Peer Support Specialist training (70 hours of live online training and 10 hours of homework, examination preparation, and attendance in office hours).(Required.)

Yes

4.I understand after completion of this 80- hour course, it will be my responsibility to apply to sit for the Medi-Cal Peer Certification Exam.

Yes

*5.I can confirm that I meet the following requirements:

I am at least 18 years of age
I possess a high school diploma or equivalent degree
I self-identify as having experience with the process of recovery from mental illness or substance use disorder, either as a consumer of these services or as a the parent, caregiver, or family member of a consumer
I am willing to share my experience
I have a strong dedication to recovery

(Required.)

Yes

*6.Are you currently Employed or Volunteer in the peer workforce?(Required.)

Yes

7.If yes, please share the following information:

Name of Organization

Position Title

Hours Per Week (Work or Volunteer)

Date Started (MM/YYYY)

Duties

Supervisor's Name

Supervisor's Email

Supervisor's Phone Number

*8.I acknowledge that I am completing an interest form and that I will be contacted if I qualify to participate in the Medi-Cal Peer Support Specialist Training.(Required.)

Yes

Create surveys and forms with ease. Sign up free.

Privacy & Cookie Notice