Family Peer Support Training Application

Family Peer Support Core Competency Training Application - March 13th - 17th, 2023

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date*

MM slash DD slash YYYY

Phone*

Email*

Enter Email Confirm Email

Organization Name (if Applicable)

Supervisors Name (if Applicable)

Supervisors E-mail address (if Applicable)

Please list your child’s diagnosis/diagnoses and describe any state-funded services they are receiving or have received (see definitions of state-funded services, below) Explanation/Clarification of Terms:*

Explanation/Clarification of Terms: Disability: an emotional, social, behavioral, and/or substance use disability that is defined in the current version of the Diagnostic and Statistical Manual for Mental Disorders (DSM). State-funded Services: To qualify for the position of Kentucky Family Peer Support Specialist (KFPSS), there must be or have been a connection between the youth’s disability/diagnosis and receipt of at least one state-funded service. Examples of state- funded services include: Kentucky IMPACT, Special Education Services, Court Designated Worker or Public Defender, services offered through a Community Mental Health Center, private child care, crisis stabilization units, or residential treatment program. These services could be provided from a variety of child-serving agencies such as: Administrative Office of the Courts; Department for Juvenile Justice; Department of Education; Department for Public Health; Department for Community Based Services; Department for Behavioral Health, Developmental and Intellectual Disabilities; Family Resource or Youth Services Centers.

Why do you want to become a Kentucky Peer Support Specialist (KFPSS)?*

What are your current responsibilities as a full-time caregiver and/or employee?*

Describe any volunteer work you have been involved in (some examples are: PTA president, Scout Leader, Habitat for Humanity, Neighborhood Association, Sunday School/Youth Leader).*

What makes you a good candidate to work with other parents and caregivers of children with mental health/substance use challenges?*

Why do you think it is important for Kentucky Family Peer Support Specialist to share their experiences?*

What does family-driven and youth-guided mean to you?*

Briefly describe the most valuable assistances/support you have received as a parent/caregiver.*

This question explores your experiences or observations about team/group work.What are some of the advantages of being part of a team?*

b. What are some of the disadvantages to being part of a team?*

Is there anything else you would like us to know in considering you for the Core Competency Training?*

Provide the following information by indicating “yes” with a CHECK mark.*

I meet the criteria outlined in the packet under eligibility section of this application.

The child mentioned above is or has been a consumer of at least one state-funded service for children with an emotional, social, behavioral, and/or substance use disability

I have successfully completed the Leadership Academy offered by KPFC and have attached/included a copy of my certificate of completion

I completed a minimum education of High School and have attached a copy of my diploma or transcript

I completed my GED coursework and have attached a copy of my GED certificate

I completed and have attached the Short Essay Form

I have provided information in every required area of this form

I understand that the Kentucky Family Peer Support Specialist Training is not a job placement program and completion of the training does NOT guarantee that I will be hired as a Kentucky Family Peer Support Specialist

I understand that if I am currently employed with CMHC, that my supervisor may be contacted to discuss my training participation

I am requesting a waiver for the thirty-five (35) hours training in accordance with this administrative regulation. Enclosed is the required documentation for the waiver

Upload Files, Diploma etc. (Optional)

Drop files here or

Max. file size: 50 MB.

Payment Option*

Make Checks payable to Kentucky Partnership for Families and Children, Inc. Mailing address: 600 Teton Trail - Frankfort, KY 40601

Family Peer Support Certification Training*

Price:

Total

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