MHAOhio 40-Hour Peer Recovery Supporter Training Application

Since 2016, have you been certified as a Peer Recovery Supporter in Ohio and had your certification lapse?

(Red * means required field)

First Name*

Last Name*

Preferred Name(Optional)

Email*

Secondary Email(Optional)

Phone*

Address*

Address 2 (Optional)

City*

State*

Zip*

County*

Please check the statements that are true for you:*

I identify as someone that has a mental health disorder.
I identify as someone that has a substance use disorder.
I want to become a Certified Peer Supporter.

Why do you want to attend this training*

Please share what you are comfortable sharing about your recovery journey. What does recovery means to you?*

Have you encountered stigma as a result of your lived experience? How have you responded?*

Please indicate your training preferences:*

*To attend a virtual training, you must be able to access a strong internet connection, a desktop or laptop computer (NO CHROMEBOOKS) with a webcam, and a private, indoor space free of distraction and other people.

I prefer an in-person training
I prefer a virtual training*
I will attend either a virtual or in-person training
I prefer a weekday training
I prefer a weekend training
I will attend a weekday or weekend training

If you require reasonable accommodation or you have barriers to attending (childcare, transportation, etc.), please describe:(Optional)

Do you have any dietary restrictions? (for in-person trainings only). (Optional)

DISQUALIFYING OFFENSES - PLEASE NOTE: Some Peer Recovery Supporters may have criminal offenses in their background as a part of their lived experience. You will learn more about past offenses and certification at the training. However, certain offenses disqualify an individual from becoming certified. Please review the list of disqualifying offenses to be sure you are eligible for certification.*

To view Disqualifying Offenses -

https://mha.ohio.gov/static/CommunityPartners/PeerSupporters/Disqualifying-Offenses-Ohio-Peer-Supporter-Certification-REVISED_040422.pdf

Are you currently on probation? If so, how much longer will you be on probation?(Optional)

Note: If you are actively on probation/parole, you cannot be certified, but can apply once you have completed your required supervision

Age*

18-24
25-34
35-44
45-54
55-64
65 and over
Prefer not to answer

Race*

Asian
Black or African American
Native American/American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
Prefer not to answer

Ethnicity*

Hispanic, Latinx, or of Spanish origin
Not Hispanic, Latinx, or of Spanish origin
Prefer not to answer

Education: What is the highest degree or level of school you have completed?*

No schooling completed
K-8th grade
Some high school, no diploma
High school graduate
Some college credit, no degree
Trade/technical/vocational training
Associate Degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Prefer not to answer

Gender*

Female
Male
Male-to-Female (MTF)/Transgender Female/Trans Woman
Female-to-Male (FTM)/Transgender Male/Trans Man
Genderqueer/gender nonconforming/neither exclusively male nor female
Other
Prefer not to answer

Sexual Orientation*

Straight or heterosexual
Lesbian, gay, or homosexual
Bisexual
Queer, pansexual, and/or questioning
Other
Prefer not to answer

Are you a U.S. Veteran?(Optional)

Are you currently employed as a Peer Recovery Supporter (PRS) or Recovery Coach?*

If employed as PRS or Recovery Coach, where are you employed?

Lived Experiences (Please check all that apply) - This information may help us connect you with job openings in settings related to your lived experience. This question is not required. You may select 'prefer not to answer' to skip it.*

ADHD
Anxiety Disorders including Panic Disorder, phobias, Social Anxiety Disorder
Alcoholism
Autism Spectrum Disorder
Bipolar and related disorders
Depressive Disorders including Major Depressive Disorder and other mood disorders
Dissociative Disorders
Drug Court
Eating Disorders
Foster Care System
HIV/AIDS
Homelessness
Human Trafficking
Incarceration
Medication Assisted Treatment (MAT)
Narcotics/Opioid use
Obsessive-Compulsive Disorder and related disorders including Body Dysmorphic Disorder, Hoarding Disorder
Other substance use
Parenting in recovery
Personality Disorders including Borderline Personality Disorder
Psychosis
Psychotic disorders including Schizophrenia, Schizoaffective Disorder
Recovery Housing
Suicidal Ideation
Trauma including Post-traumatic Stress Disorder (PTSD)
Prefer not to answer

How/Where did you hear about the Peer Recovery Supporter training/certification?*

Recommended by a friend or colleague
Treatment Provider
OhioMHAS Training Calendar
Sponsor
Employer
Other

How did you hear about PRS Training?

Please verify the following statements about the information in this application (check each box that you agree to):*

I verify I have given true, accurate, and complete information on this form to the best of my knowledge.
I understand any false information or omissions may be grounds for rejection of my application or corrective action.
I verify I am at least 18 years of age and am currently in recovery.
I verify I am an individual with a lived experience of a mental health and/or substance use disorder.
I am willing to appropriately share my recovery story.

My typed name below represents my signature on this application:*

Note: For applicants outside of central Ohio we limited spots availabel per training. It is recommended you locate a PRS training closer to your location if possible. You can view the OhioMHAS training calendar for other PRS trainings here: https://mha.ohio.gov/community-partners/peer-supporters/40-hour-peer-recovery-supporter-training-calendar