Youth and Young Adult Support Provider Training Application (May 13-17, 2019)
WE ARE ACCEPTING APPLICATIONS FOR MAY 13-17, 2019 TRAINING.
All applicants must complete the following application and meet the eligibility requirements in order to participate in the Youth Peer Support Provider Program. For our printable form (https://adobe.ly/2C15Een). You will be notified once your application is received.

Applicant Requirements:

 Between the ages of 18 and 30
 Someone living with a mental health condition, mental illness, and/or substance use
disorder.
 At least a year into your recovery
 An Indiana resident

Name *
First and last name
Your answer
Address *
Include City, State, Zip
Your answer
Email *
Your answer
Phone(s) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Estimated Date of Diagnosis *
MM
/
DD
/
YYYY
Certification Requirements
All applicants will be expected to submit to the followings screenings after the training, as well as the passing of the Youth Peer Support Provider exam, as part of the certification requirements:
● Finger-print based national and state criminal history background screen
● Local law enforcement screen
● State and local Department of Child Services abuse registry screen
● 5-Panel Drug screen
Eligibility Questionnaire
1. Have you been in recovery for at least 2 years? *
2. Are you at least 18 years of age or older? *
3. Do you have a valid Indiana driver's license AND reliable transportation? *
4. Have you earned a high school diploma or GED? *
5. Do you have basic experience with computers, including email and Microsoft Office? *
6. Are you willing and able to attend a 40-hr training? *
7. Are you currently or have you been diagnosed by a physician/psychologist with a serious mental illness (SMI), serious emotional disturbance (SED), and/or co-occurring disorder? *
8. Physician Name *
Your answer
9. Name of diagnosis(es) *
Your answer
10. Have you had at least two years experience within the last eight years living with SMI, SED, and/or co-occuring disorder? *
Please list all the system you have navigated while living with SMI, SED, and/or/ co-occurring disorder (e.g., school system, justice system, Wraparound, etc.,): *
Your answer
Please list your strengths. (If you cannot think of any, what would your friends/family say your strengths are):
Your answer
Briefly describe (5-10 sentences) your experience in the early days of your diagnosis as a youth/young adult experiencing SMI, SED, and/or co-occurring disorder. Only share what you are comfortable sharing. *
Your answer
Briefly describe (5-10 sentences) your experience today as a youth/young adult experiencing SMI, SED, and/or co-occurring disorder. Have you become involved in your own wellness? Only share what you are comfortable sharing. *
Your answer
Briefly describe (5-10 sentences) why you would like to become an Indiana Certified Youth Peer Support Provider? *
Your answer
References *
Please include the name, relationship, and contact information for three references.
Your answer
Please use this space for additional space/comments/questions, if needed.
Your answer
By 'Submitting' this form I affirm that all of the information contained in this application is true and correct to the best of my knowledge and has been completed by no other person. I understand that knowingly providing false information will be grounds to deny or terminate my certifcation.
If you have any questions or concerns, please contact Joana Goff at jgoff@namiindiana.org, or call 1-800-677-6442.
Submit
Never submit passwords through Google Forms.
This form was created inside of NAMI Indiana, Inc.. Report Abuse - Terms of Service