Community Health Worker / Certified Recovery Specialist Training Application
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1 APPLICANTS REQUIRED TO COMPLETE APPLICATION WITHOUT ASSISTANCE FROM OTHERS $35 Applicatin Fee is nn-refundable Applying des NOT guarantee admissin int training Date f Applicatin: First Name: Last Name: Hme Address: City: State: Zip Cde: Cunty: Driver s License Number, Scial Security Number r Green Card Number: (All applicants must submit ne cpy f identificatin with applicatin) Primary Phne: ( ) Secndary Phne: ( ) Persnal Address (REQUIRED): Are yu a U.S. Veteran? (Circle) Yes r N Branch f Service: Are yu a current resident f Indiana? (Circle) Yes r N Are yu ver the age f 18? (Circle) Yes r N D yu speak any ther languages ther than English? (Circle) Yes r N If yes, please list ther languages: Hw did yu hear abut us? (Circle One) CHW/CRS Website CHW/CRS Listserv Cmmunity Health Wrker Calitin Other (Please specify)
2 Have yu ever been certified thrugh ASPIN as a Certified Recvery Specialist? (Circle) Yes r N Have yu cmpleted any ther type f Peer Supprt Specialist Training? (Circle) Yes r N If yes, please list which training: Are yu currently emplyed? (Circle) Yes r N If yes, where: Psitin Title: Hw many years f experience d yu have wrking in the Mental Health Field? Hw many years f experience d yu have wrking in the Addictin Field? Hw many years f experience d yu have wrking in a rle cmparable t a Cmmunity Health Wrker? Highest Level f Educatin: (Circle) GED High Schl Diplma Assciates Degree Bachelr s Degree Master s Degree Dctrates Degree
3 Are yu in recvery frm a Mental Health Diagnsis (Other than a substance use disrder)? (Circle) Yes r N If yes, please list yur Mental Health Diagnsis: - Hw many years have yu been in recvery? Are yu currently in recvery frm a Substance Use Disrder? Yes r N - Hw many years have yu been in recvery? D yu intend t seek emplyment as a Cmmunity Health Wrker/Certified Recvery Specialist in mental health r substance abuse nce certified? (Circle) Yes r N Please circle which 5 Day Cmmunity Health Wrker / Certified Recvery Specialist training yu wuld like t attend. (Select One Training Only) 1. Cmmunity Health Wrker / Certified Recvery Specialist Training 5-Day Training August 22, 2016 August 26, 2016 Indianaplis, IN 2. Cmmunity Health Wrker / Certified Recvery Specialist Training 5-Day Training Nvember 16, 2016 Nvember 20, 2016 Frt Wayne, IN 3. Cmmunity Health Wrker / Certified Recvery Specialist Training 5-Day Training March 6, 2017 March 11, 2017 Indianaplis, IN
4 Please write cmplete answers t the fllwing questins withut utside help. Please make sure yur answers are in cmplete sentences and that yur handwriting is clear and legible. Please cnfine yur respnses t the spaces prvided fr each questin. 1. What des recvery mean t yu?
5 2. What were the mst imprtant factrs in yur wn recvery? 3. Why d yu want t becme a Cmmunity Health Wrker/Certified Recvery Specialist?
6 4. What makes yu a gd candidate t wrk with ther cnsumers in recvery frm a mental health issue, gambling disrder, substance use disrder r chrnic health cnditin? 5. What types f experiences have yu had in advcating fr cnsumers f mental health services, gambling disrders, substance use disrders r chrnic health cnditins? Please describe in detail, listing effrts in letter writing, persnal advcacy, public testimny, and prgram wrk.
7 6. Describe yur current emplyment r vlunteer wrk. If neither applies, hw d yu spend yur time? 7. What will be yur mst difficult challenge in attending the training? Hw will yu deal with that challenge?
8 8. D yu need special accmmdatins in rder t attend training? If s, please explain. T ensure a cmplete applicatin, please als send in the fllwing: $35 mney rder nly (made ut t ASPIN) A cpy f ID (Driver s License, State ID, Scial Security Card, Green Card) Prf f recvery frm mental illness and/r addictin via: - Treatment Verificatin Frm OR - Bth the Persnal Reference Frm and Self-Attestatin Frm INCOMPLETE APPLICATIONS WILL BE SHREDDED. Please mail all dcumentatin t: ASPIN CHW Prgram Crdinatr 8440 Wdfield Crssing Bulevard Suite 460 Indianaplis, IN Yu will receive an acknwledging receipt f yur applicatin and fee. N phne calls, please. Thank yu! Yur signature Date:
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