Certified Youth Peer Support Training Application Form

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* 1. Contact Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support.

Yes

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* 3. County of Residence

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* 4. Date of Birth

MM/DD/YYYY

Date

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* 5. Please check the boxes that are applicable:

I believe individuals with mental health, addiction, and trauma experiences can embark on a recovery journey.

I believe there are multiple pathways to recovery for individuals with lived experience.

I am open and willing to appropriately share my story.

I need reasonable accommodations for the trainings. If yes, please share more information below.

Accommodations:

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* 6. I have personal lived experience with the following child-serving systems (please select all that apply):

Behavioral Health (Mental Health)

Behavioral Health (Addiction)

Juvenile Justice

Developmental Disabilities

Child Welfare

Education (IEP/504)

Certified Youth Peer Support Training Application Form

Question Title

* 1. Contact Information

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* 2. I agree that OhioMHAS can share my address with YouthMOVE solely for the purpose of sending materials related to Youth Peer Support.

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* 3. County of Residence

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* 4. Date of Birth

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* 5. Please check the boxes that are applicable:

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* 6. I have personal lived experience with the following child-serving systems (please select all that apply):

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* 7. Please share some brief information related to your wellness recovery journey.

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* 8. Why are you interested in becoming a Certified Youth Peer Supporter?