Registration Form for the Peer Services in Crisis Care Training Program 40-Hr
Thank you for your interest in WERC’s Peer Services in Crisis Care Specialization Training Program! Please complete this form to register.
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General Registration for Medical Peer Support Program
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Passed Certification Exam
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Registration Status Notes
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Additional Request
Accommodation Needed
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Office Hours Appointment
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Appointment Date
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Appointment Notes
Cancellation
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Feedback Notes
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Cancellation Approval Date
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Leave of Absence
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Date of Request
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Approval Date
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Training Program Extension
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Training Completion Date
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Assignment Packet
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Full Name
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First Name
Last Name
Middle Name
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Last Name Chosen
Work Email
example@example.com
Personal Email
*
example@example.com
Please, select preferred email for enrollment and communication process.
*
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Personal
Work
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
When did you receive your CalMHSA Peer Support Specialist Certification?
*
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County of Residence
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Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
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Shasta
Sierra
Siskiyou
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Tehama
Trinity
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Tuolumne
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Yolo
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Ethnicity
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Asian
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Gender
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Male
Female
Non-Binary
Trans-F
Trans-M
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Age
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18-25
26-64
65+
Proficient Languages (Please, select as many as apply).
*
English
Spanish
American Sign Language
Arabic
Armenian
Cambodian
Cantonese/Mandarin
Farsi
Hindi
Hmong
Japanese
Korean
Lao
Punjabi
Russian
Tagalog
Thai
Vietnamese
Please, select all the options one by one by pressing Control/CTRL+ click.
At this time, WERC is offering the training in English. WERC may offer training in additional languages in the future. If you would like to be placed on a list to learn about a future training offered in a different language, please check this box, complete the rest of this form, and click Submit. Thank you again for your interest in WERC’s Medi-Cal Peer Support Specialist Certification Training Program!
*
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Do you plan to make a request for accommodation in order to participate in the training program?
*
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Yes
No
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Sexual Orientation
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Heterosexual
Lesbian
Gay
Bisexual
Queer
Asexual
Pansexual
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Are you a single parent?
*
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No
Individual income
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School Status
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Currently in school
Currently out of school
Highest Education level completed
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No high school diploma or equivalent
High school diploma or equivalent
Some postsecondary education
Postsecondary certification (non-degree)
AA/AS degree
BA/BS degree
Graduate degree
Are you in/have been in foster care?
*
Please Select
Yes
No
TAY
*
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Yes
No
Formerly
Veteran
*
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Yes
No
Receiving Veterans Benefits
*
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Yes
No
Receiving CalFresh/FoodStamps
*
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Yes
No
Receiving Gain/Calworks
*
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Yes
No
Receiving Supplemental Security Income
*
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Yes
No
Unemployment Compensation Eligibility
*
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Claimant,
Exhaustee
Neither claimant nor exhaustee
Receiving GeneralRelief/GROW
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Yes
No
Receiving Social Security Disability Ins
*
Please Select
Yes
No
Employment Status
*
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Employed
Underemployed
Not in the labor force
Unemployed
Long term unemployed (27 consecutive weeks)
Are you currently employed in a peer support role?
*
Please Select
Yes
No
Type of Employer
*
Please Select
Behavioral Health County Agency
Community Based Organization
Peer-Run Organization
Name of Employer
*
Employer County
*
Please Select
Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Years with Employer
*
Employer Address
*
Do you have a CalMHSA voucher?
*
Please Select
Yes
No
Voucher Number/Code.
*
Please upload a copy of the email you received from CalMHSA, listing your name and your scholarship unique ID number. If you have a voucher and cannot upload it using this form, please email a copy of your voucher to mpssc@we-rc.org within 24 hours of your registration submission. You can also contact us if you need additional technical assistance.
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Non-voucher Holder
Please list your employer's (or sponsoring organization's) accountant information. WERC will follow up with an invoice to process payment with your employer.
If you are paying it out of pocket, please put in your name and details below.
Employer/Sponsoring agency name
*
Employer/Sponsoring agency address
*
Employer/Sponsoring agency address 2
*
City
*
Zip code
*
State
*
Accountant Name
*
If you are paying it out of pocket, please put your name and details below.
Accountant Email
*
example@example.com
Accountant phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
WERC is committed to supporting an inclusive learning environment. Eligible participants may request reasonable accommodation. WERC will determine on an individual basis if accommodation can be provided. To make a request, please contact the WERC team at mpssc@we-rc.org.
WERC's Medi-Cal Peer Services in Crisis Care Training Program is a self-paced 40-hour online course. You will have 6 months to complete the training from the date of registration.
WERC is an equal opportunity training organization committed to diversity, equity, and inclusion. We are excited to offer a training program for peer specialists with lived experience in areas such as housing instability, justice system involvement, substance use disorders, mental illness, and other areas.
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