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First & Last Name

Email Address

Organization/Agency

Organization/Agency website

Address

Office Phone

Mobile Phone

Job Title

Length of time in current position

Are you a trained Peer Recovery Specialist?

Are you Certified?

Name of Certification

State of Certification

Do you self identify as a person who would qualify as a Certified Peer Recovery Specialist?*

If yes, please explain

Which is the PRIMARY location and date of the training you are interested in taking?

Do you have any special needs for participation (e.g. dietary or other requirements/accommodations)?

If yes, explain

Please submit a Motivation Letter (not to exceed 400 words), describing in your own words what professionalism is and why it is an important component of peer/recovery support

Please type your first and last name as an electronic signature**

Please type today's date

Send me a copy

*Peer Recovery Specialist are required to role model a recovery journey of their personal experience with behavioral health challenges (mental health and/or substance use disorder) OR their experience as a parent of a child with mental illness and/or substance use disorder, or an adult with an on-going and/or personal experience with a family member with mental illness and/or substance use disorder.

**BY SIGNING AND SUBMITTING THIS APPLICATION FOR CCAR Recovery Coaching and Professionalism, I DO HEREBY AGREE TO COMPLETE THE ENTIRE TRAINING, OTHERWISE, I WILL BE OBLIGATED TO PAY THE FEE FOR THE COURSE

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