Peer Wellness Specialist Application

Veteran's Peer Wellness Specialist Training Application
Complete applications will be reviewed on a first-come, first-serve basis. There is limited spots available. This grant is being provided by Oregon Health Authority's Veteran Behavioral Health Services Division to support the workforce development for Service Members and Veterans.

Once you complete this application, you will receive a confirmation email that it has been submitted. If you have any specific questions, please reach out to the Director of OPTIC, Emily Nelson at enelson@mhaoforegon.org.

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 has a working knowledge of the various health care and wellness resources in their community and how to access these services and resources.
Training Schedule

9:00 am to 5:00 pm

September 22nd - 24th
October 1st - 3rd
October 7th - 10th
Training Location:

COCC Barber Library:
2600 NW College Way, Bend, OR 97703
Name*

FirstLast
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Age Range*
YesNo
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.)*
African American/BlackHispanic/LatinoAmerican Indian/Alaskan NativeWhite/CaucasianAsianNative Hawaiian/Pacific IslanderMiddle Eastern/North AfricanDecline to AnswerOther
YesNo
YesNo
HonorableUnder Honorable ConditionsOther Than HonorableOther
EmployedUnemployedStudent
YesNoDon't want to answer/DeclineOther
How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?
Social Security Number*
We cannot process the application without this information. Information provided will be kept confidential.
Lived Experience

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.
YesNo
YesNo
YesNo
Education and Training
Identify any Peer Support training 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 become a Peer Wellness Specialist?*
Do you have any concerns about this line of work or participating in this training?*
How did you hear about our training?*
Should be Empty:

Veteran's Peer Wellness Specialist Training Application

Education and Training

Supplemental Questions