Application for Medi-Cal Peer Support Specialist Certification Training

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* 1. Are you a California (CA) resident?

Yes

No

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* 2. Age:

16 or Under

17

18-25

26-64

65+

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* 3. Do you have at least a GED or High School Diploma

Yes

No

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* 4. Are you an individual with "lived experience" (someone who has received services for a mental/substance use disorder/behavioral health issue or are a family member or caregiver who has assisted someone with these services) and are dedicated to helping people recover from similar experiences?

Yes

No

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* 5. What is your Date of Birth?

Date / Time

Date