Registration Form for the Medi-Cal Peer Support Specialist Continued Education Course- Emotional Intelligence in the Workplace
This form is a first step for registering yourself to WERC continued education course Please, review each field carefully and provide response to each require field accordingly.
Enrollment Date
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Day
Year
Date
Registration Status
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In Review
Pending RISE Account Activation
Enrolled
Missing Voucher Code
Waitlist for Future Training
Cancelled Registration
Leave of Absence
DUPLICATE
Certificate Awarded
Pending Invoice Approval
Enrolled-WERC Scholarship
Not completed
Course Start Date
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Course Completion Date
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Course Progress
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Not Started
Complete
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Registration Status Notes
0/32768
Additional Request
Accomodations Needed
Cancellation
Office Hours Appointment
Cancellation Request
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Yes
No
Cancellation Approval Date
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Day
Year
Date
CalMHSA certification issue date
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Day
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Date
Passed Certification Exam
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Yes
Status Pending
Needed Accommodation
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Yes
No
Office Hour Appointment
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Yes
No
Date of Request
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Month
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Day
Year
Date
Appointment Date/Time
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Month
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Day
Year
Date
Appointment Notes
Participant Name
*
First Name
Last Name
Middle Name
*
What is your chosen name?
Work Email
example@example.com
Personal Email
*
example@example.com
Preferred Email
Please Select
Personal
Work
Alternate
Mobile
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Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Age
Please Select
18-25
26-64
65+
When did you recieve your CalMHSA Certification?
*
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Month
-
Day
Year
Date
CalMHSA Certification
*
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Uplaod vaild MPSS Certification
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Race/Ethnicity
*
American Indian/Alaskan Native
Asian/Pacific Islander
Black/African American
Hispanic/Latinx
White/Caucasian
Gender Identity
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Male
Female
Non-binary
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Veteran
*
Please Select
Yes
No
Are you in/have been in foster care?
*
Please Select
Yes
No
Receiving CalFresh/FoodStamps
*
Please Select
Yes
No
Receiving Gain/Calworks
*
Please Select
Yes
No
Receiving GeneralRelief/GROW
*
Please Select
Yes
No
Receiving Supplemental Security Income
*
Please Select
Yes
No
TAY
*
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Yes
No
Formerly
Receiving Social Security Disability Ins
*
Please Select
Yes
No
Receiving Veterans Benefits
*
Please Select
Yes
No
Employment Status
*
Please Select
Employed
Underemployed
Not in the labor force
Unemployed
Long term unemployed (27 consecutive weeks)
Unemployment Compensation Eligibility
*
Please Select
Claimant,
Exhaustee
Neither claimant nor exhaustee
Are you single parent?
*
Please Select
Yes
No
Individual income
*
School Status
*
Please Select
Currently in school
Currently out of school
Highest Education level completed
*
Please Select
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
Requesting Accommodation
*
Please Select
Yes
No
Are you currently employed in a peer support role?
*
Yes
No
Type of Employer
*
Please Select
Behavioral Health County Agency
Peer-Run Organization
Community Based Organization
Name of Employer
*
Employer County
*
Years with Employer
*
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list your employer's (or sponsoring organization's) accountant information. WERC will follow up with an invoice to process payment with your employer.
Employer/ Sponsoring Agency Name
*
If sponsoring agency is not available, registrants can add their information if paying out-of- pocket.
Employer/ Sponsoring Agency Name
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Accountant Name
*
First Name
Last Name
Accountant Email
*
example@example.com
Accountant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
WERC's Medi-Cal Peer Services, Continued Education Course is a self-paced 2-hour online course. You will have1 year 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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