Peer Specialist Training Application

Peer Specialist Training Application

Thank you for your interest in the Peer Specialist Training Program. Please complete the following program application form carefully, providing honest and thoughtful responses. Your answers will help program staff ensure that the program adequately supports your training and employment goals.

Last Name*

First Name*

Middle Name/Initial

Phone Number*

Phone

Email Adress*

Date of Birth*

Address*

City*

Zip Code*

Are you a military service member?*

Yes

Branch

Discharge Date

Justice Involvement Status*

No prior involvement with the justice system

Previously incarcerated

Justice-involved, no prior incarceration

Currently on probation/parole

Program of Interest*

Medi-Cal Peer Support Specialist

Vet2Peer

Peer Training for Youth

Peer Training for Justice Impacted Individuals

Are you current or former LMU student?*

I am a current LMU Student

I am a former LMU Student

I am neither a current or former LMU Student

If you are currently employed, please provide the following information

Employer

Position

Please tell us about any involvement in volunteer work or involvement with community organizations related to mental health or substance abuse. If you are currently involved in volunteer work, please provide the name of the organization

Do you have any lived experience with mental health, substance abuse, or other relevant challenges?*

Yes

Have you experienced any of the following in the last 2 years? (Select all that apply)*

Please indicate your digital literacy levels (Select all that apply)*

I am able to meet the basic technology requirements to participate in an on-line class and/or complete required coursework. (Select all that apply)*

I have access to a device - laptop, tablet, or desktop computer- other than a smartphone

I have access to reliable internet connection, other than a smartphone

I have access to a webcam for required class participation other than a smartphone (online classes)

I do not have access to basic technology requirements, other than my smartphone

How do you envision using your peer support skills in your future career?*

Please indicate any factors or circumstances that may hinder your ability to secure employment upon completion (Select all that apply)

Lack of Transportation

Family Responsibilities (childcare, eldercare)

Language or Literacy Challenges

Financial Constraints

Please tell us about your mental health journey. How have these experiences influenced your personal or professional growth?"*

How did you hear about the LMU Peer Support Specialist Training?

I understand that this training program is supported by a state workforce development grant and requires employment or volunteering in peer-related occupations.

I understand the program requires my participation in career development services including, but not limited to career plan development, resume writing, cover letters, interview preparation., and placement assistance

I understand that I am required to report employment upon completion of the program

I understand that I must observe all program requirements and code of conduct during all classroom activities and interaction with faculty, staff, and peers.

I grant LMU permission to use my photograph or other digital media in any and all of its publications, including web-based publications, university articles, and promotional materials.

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