Three Day Forensic Peer Support Training_Application FINAL
- 1. Veterans Peer Support and the Criminal Justice System Three-Day Forensic Training Application November 16-18 2015 8:30am-4:30pm *There is a cap of 25 attendees* Location: OIM Training Center 123 Boro Line Rd King of Prussia, PA 19406 This application is for the three-day Veterans Peer Support & Criminal Justice System Training. Cost is $90.00 payable with application. Please note: the three-day training is open only to Certified Peer Specialists who have served in the military. By submitting this application, you are attesting that you are a certified peer specialist and served in the military. Preference is given to Pennsylvania residents. If you need accommodations to complete this application, contact PMHCA at pmhca.@pmhca.org or call (717) 564-4930 or 1-800-887-6422. Section 1: General Information Name: County: Address: 1 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015
- 2. Section 1 continued Email: Phone number(s): Current place of employment or volunteer work: Job title (if applicable): Preferred method of contact (circle or underline): Email Letter (postal mail) Section 2: Knowledge & Experience Please briefly answer the following questions. Do you have experience with the criminal justice system? (As a mental health consumer, have you yourself had contact with the criminal justice system?) What is your current involvement? For example, do you serve on a county CJAB? Provide peer support to people who are navigating the criminal justice system? Please explain to whatever degree you feel comfortable. 2 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015
- 3. Section 2 continued Does your county of residence have a Criminal Justice Advisory Board (CJAB)? If so, is there mental health representation on the CJAB? Please share your knowledge or experience of your county mental health system. (We ask this so that you begin to think about how you will use the info in this training and what will you do to bring the information you gain back to your county.) Section 3: Interest & Involvement Please briefly answer the following questions. Why are you interested in attending the Peer Support & the Criminal Justice System Training? 3 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015
- 4. Section 3 continued What is your experience in leadership roles, if any? Section 4: Other Information Do you need any special accommodations for the duration of the training (including linguistic needs, dietary restrictions, access, etc)? If so, please list them here. (Note: this has no bearing on the applicant selection process.) Please list two emergency contacts (people we can call if you have an emergency occur during the training): 1) Emergency Contact #1: a. Name: b. Relationship to you: c. Phone number(s): 2) Emergency Contact #2: a. Name: b. Relationship to you: c. Phone number(s): 4 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015
- 5. Please print your name, sign, and date. If sending by email, please just type/print your name & fill in the date: Printed name: _______________________________________________ Signature: ___________________________________________________ Date: ___________________ Please email (preferred), fax, or mail this completed application and a copy of your CPS certificate to: PMHCA 4105 Derry St. Harrisburg, PA 17111 Email: pmhca@pmhca.org Fax: 717-564-4708 Please note: All applications must be received by the end of the business day on October 30th, 2015 to be considered. If faxing your application, please write your name at the top of each page and include a cover page, to ensure that your entire application is kept together. *The training is co-sponsored by PMHCA and the Office of Mental Health and Substance Abuse Services of the Pennsylvania Department of Human Services.* 5 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015
- 6. Please print your name, sign, and date. If sending by email, please just type/print your name & fill in the date: Printed name: _______________________________________________ Signature: ___________________________________________________ Date: ___________________ Please email (preferred), fax, or mail this completed application and a copy of your CPS certificate to: PMHCA 4105 Derry St. Harrisburg, PA 17111 Email: pmhca@pmhca.org Fax: 717-564-4708 Please note: All applications must be received by the end of the business day on October 30th, 2015 to be considered. If faxing your application, please write your name at the top of each page and include a cover page, to ensure that your entire application is kept together. *The training is co-sponsored by PMHCA and the Office of Mental Health and Substance Abuse Services of the Pennsylvania Department of Human Services.* 5 OMHSAS/PMHCA Veterans Forensic Peer Support Training November 2015