Culturally Specific Afrocentric Peer Wellness Specialist Training Application

Culturally Specific Afrocentric Peer Wellness Specialist Training Application

Complete applications will be reviewed on a first come, first serve basis. Please note that training spaces are limited.
The role of the Peer Wellness Specialist is to provide peer support, encouragement and assistance to address physical and mental health needs. In order to do that, it is important that the Peer Wellness Specialist have a working knowledge of the various health care and wellness resources in their community and how to access these services and resources.

Training Details

Culturally Specific PWS Training
____________________________________________________

Format: Virtual via Zoom
Cohort Preference

December 1st-December 17th Culturally Specific PWS Training
This training was developed and created for Peers who identify as Black or African American. Do you identify as part of this community? If you "No" please sign up for the non-specific PWS training.*

YesNo
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Age Range*
Social Security Number*
We cannot process the application without this information. Information provided will be kept confidential.
Optional Questions

The following four questions assist us in reporting statistical information. You may decline to respond.
Do you currently live in a rural community (population of 50,000 or less)?
Have you served in the military?
Employment status?

UnemployedEmployedStudent
What is your race and/or ethnic identity?
What is your preferred language?
Please note that this question is for statistical purposes only. Unfortunately, we do not have the ability to provide interpreter services.
Are currently in the THW Registry?

YesNoUnsure
Lived Experience
Do you identify as being in recovery from mental health challenges? *
Do you identify as being in recovery from a behavioral addiction or substance use issue? *
Do identify with having a physical health condition(s)?*
Per Oregon Administrative Rule (OAR) 410-180-305, MHAAO provides the following certificates to participants of its Peer Wellness Specialist training program: Certificate of completion will be provided to participants who meet all required instruction, demonstrate achievement of all competency requirements, and have life experience as defined in OAR 410-180-305 if applying for Peer Peer Wellness Specialist certification from the Oregon Health Authority. Only a certificate of completion is acceptable proof of training to receive certification from the state. Certificate of attendance will be provided to those who attend and participate in the training but do not identify as having lived experience.
Education and Training
Identify any peer support training that you have received in the past.
Have you been certified through another Peer Support Specialist or Peer Wellness Specialist training program in Oregon or elsewhere?
What is the highest level of education you have completed? *
Supplemental Questions
Why do you want to work as a Peer Wellness Specialist? *
Do you have any concerns about this line of work or participating in this training?
How did you hear about this training opportunity?*
Are there barriers to you participating in the training?

YesNoUnsure
If yes, please describe.
We may have the ability to support you in reducing some barriers to support your ability to participate.
Do you have access to a tablet, laptop, or desktop computer? (Mobile devices do not allow for full participation thought out training course.)*

YesNo
Does your device have audio and video capabilities?*

YesNo
Do you have access to stable internet connection?*

YesNo
Funding
Funding Source*
Funder Name/Scholarship Awarded*
Funder Email*
example@example.com
Funder Phone Number

Area CodePhone Number
Should be Empty:

Culturally Specific Afrocentric Peer Wellness Specialist Training Application

Optional Questions

Lived Experience

Education and Training

Supplemental Questions

Funding