REGISTRATION FOR COMMUNITY VOICE GATHERING ABOUT THE EMERGING PEER PROFESSION

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* 1. Name:

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* 2. Address:

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* 3. Email:

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* 4. Phone:

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* 5. If you plan on bringing other participants, please list how many.

Please check off number:

1 additional person

2 additional persons

3 additional persons

4 additional persons

5 additional persons

6 additional persons

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* 6. Gathering You Would Like to Attend?

All Gatherings will be held from 10:00-1:30 PM (Registration 9:30-10:00)

Metro-Boston, Reggie Lewis Arena, Roxbury, Tuesday May 27th

Metro Suburban, Quincy Mental Health Center, 460 Quincy Ave., Cafeteria Wednesday June 11th

Southeast, Taunton Hospital, Ricky Silva Gymnasium, Friday June 13th

Northeast, Renaissance Club, Lowell, Wednesday June 18th

Central, UMASS Center for Health Policy & Research, Shrewsbury, Friday June 20th

Western, Holyoke Community College, Kitteridge Center, Holyoke, Monday June 2nd

If you plan on coming to more than one gathering, please list here.

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* 7. How would you describe yourself?

Department of Mental Health Employee

Mental Health Service Provider

Certified Peer Specialist

Peer Worker

Other (please specify)

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* 8. Please check your preference for the Break-out Group

CERTIFIED PEER SPECIALIST(CPS) CODE OF ETHICS DISCUSSION--The CPS Code of Ethics defines ethical boundaries which are clear, but quite distinct from other mental health provider boundaries. In this break-out group we will discuss challenges while working and how continuing education may help to remedy these challenges.

WELLNESS RECOVERY ACTION PLAN (WRAP) & WHOLE HEALTH ACTION MANAGEMENT (WHAM) DISCUSSION--This session will look at fidelity to development of each persons self efficacy. We will also look at collaborations that are expanding in the community now.

DIVERSIFYING THE PEER WORK FORCE & PROMOTING A CULTURE OF RESPECT- How we are identified (culture, class, sexual orientation, age, language proficiency, etc) tends to relate to differences in our recovery and health outcomes. This break-out group will explore how affinity groups, building allies and a more diverse workforce can improve the quality of individual and community life.

Thank you! We look forward to seeing you at the regional gathering! If you have any questions, please call Ruthie Poole at the Transformation Center at (617) 442-4111 or email ruthiep@transformation-center.org

NOTE--IF YOU NEED AN ASL INTERPRETER, YOU MUST CALL OR EMAIL US. THANK YOU!

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* 1. Name:

Question Title

* 2. Address:

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* 3. Email:

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* 4. Phone:

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* 5. If you plan on bringing other participants, please list how many.Please check off number:

Question Title

* 6. Gathering You Would Like to Attend?All Gatherings will be held from 10:00-1:30 PM (Registration 9:30-10:00)

Question Title

* 7. How would you describe yourself?

Question Title

* 8. Please check your preference for the Break-out Group

* 5. If you plan on bringing other participants, please list how many.

Please check off number:

* 6. Gathering You Would Like to Attend?

All Gatherings will be held from 10:00-1:30 PM (Registration 9:30-10:00)