JUST 1 LIFE - PRSS INTAKE PACKET - Please complete all forms prior to initial appointment.

Demographic Information

Client First Name

Client Last Name

Preferred Name

Date of Birth

Phone Number

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Street Address

Apt #

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City

State

Zip Code

Gender

Employer Name

Job Title

Emergency Contact Full Name

Emergency Contact Phone Number

Emergency Contact Email address

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Payment / Insurance Information

AHCCCS / Member ID

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PEER SUPPORT EMPLOYMENT TRAINING PROGRAM APPLICATION

POLICY 963 - ATTACHMENT B

Name of Training Program: Just 1 Life - Peer Support Training program / by Justin D.L. Harvey

Completing this interview and meeting all requirements of this application does not guarantee admission into a Peer Support Employment Training Program (PSETP). Training programs may have other requirements such as assessments, referrals, additional forms, background checks and/or tuition which must be completed or paid prior to admission.

Do you understand this and have you satisfied all the requirements of the program to which you are applying?

Yes

Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?

Yes

Completion of a Peer Support Employment Training Program is not a guarantee of employment.

Do you understand and agree to this?

Yes

Self-identification as a person with lived experiences of behavioral health conditions is a requirement to receive a PRSS credential. Upon completion of this program your name, the name of the training program, date of graduation and current employer (if applicable) will be transmitted to AHCCCS as specified in AMPM Policy 963.

Do you understand and agree to this?

Yes

This Peer Support Employment Training is intended to prepare you to practice and deliver peer support services in the AHCCCS (Medicaid) programs.

When did you decide you wanted to become a peer support?

What are you looking forward to most about this training?

Peer & Recovery Support Specialists (PRSS) aka: Peer Supports often spends a lot of time doing paperwork and may have other duties unrelated to practicing and delivering peer support services. Is there anything about that concerns you?

If nothing about that concerns you type "nothing".

Some work environments may seem more Recovery-Oriented and more welcoming than others. Do you have any concerns about working as a PRSS in environments that you may feel are less Recovery-Oriented and less-welcoming?

If nothing about that concerns you type "nothing".

A Peer & Recovery Support Specialist (PRSS) is an individual who has lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and significant life disruption, for which they have received treatment and or support for; and they can now demonstrate and share the experience and self-directed recovery, including knowledge of approaches to support the recovery of others.

Can you willingly self-identify to others as having lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and significant life disruption, for which you have sought support?

Yes

Have you been managing and maintaining my own recovery and wellness for a minimum of one (1) year? *Keeping in mind, this does not mean that you have been free from all substance use and or MH issues? (Harm reduction)

Yes

Are you willing to share these lived experiences, when appropriate, for purposes of education, role modeling and providing hope to others about the reality of recovery?

Yes

Are you willing to share what you have had to overcome to get where you are in your recovery?

Yes

Are you willing to share what having “lived experience” means to you?

Yes

Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

Yes

The training program requires complete attendance for the duration of the training.

If accepted to this program, can you commit to the attendance requirements?

Yes

Are there any barriers which may keep you from attending the entire training (e.g. childcare, work schedule, transportation)?

Yes

If yes please describe.

The training is highly interactive and requires activities involving small group work, role-playing, and reading aloud to the class.

Are you comfortable with this kind of participation?

Yes

As part of the training you will be asked to participate in discussions, role-plays, and to share your personal story of recovery in front of the class.

Are you comfortable with this kind of participation?

Yes

During the training you will listen to the recovery stories of others. Sometimes these stories may be uncomfortable to hear.

Are you willing to communicate any discomfort to the trainers if this were to happen?

Yes

What do you see as being the most difficult challenge in PRSS training, and how will you approach it?

If nothing about that concerns you type "nothing".

Are there any accessibility needs for you to fully participate in the training? (e.g. service animal, note taker, large text, sign language interpreter)?

If no special accommodations are needed type "no".

Client Full Name

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Today's Date

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JUST 1 LIFE - PRSS INTAKE PACKET

Demographic Information

Payment / Insurance Information

PEER SUPPORT EMPLOYMENT TRAINING PROGRAM APPLICATION

Just 1 Life Services LLC