PROJECT PEER (PEER EDUCATION AND EXPERIENCE ROADMAP) II WRITTEN APPLICATION

Basic Eligibility

In order for individuals to begin the application process, they must meet the following criteria:

1) 18 years or older.

2) Have lived experience with a mental health or mental health and addictions challenge.

3) Plan to work (or currently working) within the peer support or behavioral health fields.

4) Willing and able to complete both training and internship hours.

5) Not listed on the federal suspension or debarment list (and thus ineligible to receive federal funds).
Name*

First NameLast Name
How do you like to be referred to?
You may give us your pronouns here
Address*

Street Address Line 2

Street Address Line 2

CityState / Province

Postal / Zip Code
City*
Zipcode*
Phone Number*
Are you comfortable with someone from Project PEER leaving a voicemail to the phone number you provided?*

YesNo
Are you comfortable with someone from Project PEER texting you at the phone number you provided?*

YesNo
Email*
What is your preferred method of contact?*

EmailPhone
Birthdate*
Month/day/year
Project PEER eligibility includes planning to work or currently working within the peer support or behavioral health fields. Which of the following is true for you?*

I do not currently work, but I plan to work in peer support / behavioral health.I currently work within peer support / behavioral health fields, and plan to continue.I currently work within an unrelated field, and plan to work in peer-delivered services in the future.I do not plan to work in peer support or behavioral health in the future.
The following questions help us better understand who we are serving. They are required by the funding agency (HRSA) for reporting purposes. If you have questions or concerns regarding these questions, please feel free to reach out.
Do you currently live in a rural area?*

YesNo
Have you ever lived in a rural area?*

YesNo
If you have ever lived in a rural area, where? Please provide the zip code (if known) or city and county.
Zip code
Are you a Veteran?*

YesNo
How would you describe yourself?*

Native American, Alaska Native, or IndigenousAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteLatinx/HispanicPrefer to self-describeOther
If you chose 'prefer to self-describe' for the previous question, please explain if you are comfortable.
With which underrepresented group(s) do you most identify, if any? (i.e. Veteran, LGBTQ+, minority group, rural resident, Youth, formerly houseless, formerly incarcerated, other?)
Do you speak more than one language?*

YesNoPrefer not to Answer
If you chose yes for the previous question, which languages do you speak and would you be comfortable providing services in them?
Do you identify as having lived experience of mental health challenges?*
Do you identify with the lived experience of having used substances or had a substance use disorder, and are in recovery? If yes, do you have at least 2 years of recovery?*
If you chose yes for the previous question, how many years of recovery do you have?
Do you identify as having lived experience of having behavioral addictions, like gambling? If yes, do you have at least 2 years of recovery*
If you chose yes for the previous question, how many years of recovery do you have?
Peer Support Background

Please note that you may include a resume or CV to answer these questions. You may upload your attachments at the bottom of this form.
Describe any peer supports that you have received in the past and currently.
Identify any peer support training that you have received and if you have been certified through another peer support specialists or peer wellness specialists training program in Oregon or elsewhere. You may include this in the form of a resume and attach it to your application.
Describe paid or volunteer peer support services that you have provided including the name of the organizations, time periods, job descriptions, and who you served. You can provide this in the form of a resume and attach it to your application.
As part of this program there is a 100-hour internship requirement. Do you currently work somewhere or know of somewhere this can be completed? Please note that it is not a requirement to have already identified an internship site.*

YesNoI'm not sure
If you chose yes for the previous question, please explain.
Other Work History

Please note that you may include a resume or CV to answer these questions. You may upload your attachments at the bottom of this form.
Describe other current and former paid or volunteer jobs through which you have gained experience working with people with lived experiences with mental health challenges and/or youth and young adults. You may provide this information in your resume.
Please describe other work experiences that you have had.
Other Education and Training

Please note that you may include a resume or CV to answer these questions. You may upload your attachments at the bottom of this form
Describe education and training other than peer supports that you have received including high school, GED, college, and technical training courses and programs. You may provide this information in your resume.
Please provide at least one letter of recommendation, specifically speaking to your ability to successfully complete the program. Please reference things you have completed in the past that speak to your reliability and dependability. The letter(s) of recommendation may written by a reference that can be personal, academic, or professional. It could be someone you have worked or volunteered for, a long-time friend, sponsor, employer, teacher, etc.*

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Thank you for your interest in Project PEER.
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PROJECT PEER (PEER EDUCATION AND EXPERIENCE ROADMAP)

Peer Support Background

Other Work History

Other Education and Training

Thank you for your interest in Project PEER.