APPLICATION to ATTEND
Iowa Peer Support Training Academy
Dates of Training:
Sunday, August 26 – Thursday, August 30, 2012, and
Thursday & Friday, September 13-14, 2012
Location: EWALU Camp & Retreat Center, Strawberry Point, IA
For more information on the Iowa Peer Support Training Academy, please
contact Lila Starr at the Iowa Department of Human Services,
lstarr@dhs.state.ia.us, or 515-281-5318.
PLEASE BE ADVISED: Preference in this particular session of training will be given to persons who are
currently volunteers in a Peer Support setting in NE Iowa (Northeast Iowa Behavioral Health (NEIBH) in
Decorah ).
Other applicants will be considered for additional openings.
All SEVEN days of training are mandatory, and must be attended by all trainees.
Part A
Electronic submissions of Part A are encouraged, but follow up via regular mail will also be needed, so
that original signatures and initials on the application, and signatures on any letters of support, will be
available for review by the selection committee.
Part B Part B should be handwritten.
Please provide at least two letters of support with your application.
It is recommended that you seek letters of support from your colleagues and supervisors involved in
mental health organizations, to include but not limited to advocacy organizations, community mental
health centers, recovery centers, drop-in centers, 12-step programs, and other groups focused on recovery.
The following guidance includes things that are helpful to request that the person include in each letter of
support:
· Describe the applicant’s strengths that they would bring to the field as a mental health peer support
specialist.
· If the author is in a position to hire the applicant, have them mention their interest in hiring the
individual.
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· Provide examples of the applicant’s involvement in recovery-based mental health or other initiatives and
activities (i.e. self-advocacy, leadership in mental health programs and services, training, lived
experience, etc.).
· Have the author of the letter of support describe his or her familiarity with peer support, the Iowa Peer
Support Training Academy, the Academy curriculum, and the rigor of the training week.
· Have the author describe the applicant’s readiness to attend and fully participate in the training
and provide a rating of readiness on a scale of 1-10, with 10 being extremely ready and 1 being not
at all ready.
· Have the author identify themselves, their position, agency, and contact information.
Accommodations
Please let us know if you request any disability related accommodations and tell us what accommodations
you request. Verification and documentation of need for any requested accommodations must be
provided.
Accommodations Requested (be specific, and provide details on documentation with your application):
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Return Part A, Part B, documentation for any requested accommodations, and
Letters of Support to:
Iowa Department of Human Services
Attn: Lila P.M. Starr
1305 E. Walnut
5th Floor Hoover Building
Des Moines, IA 50309
Fax 515-242-6036
Phone 515-281-5318
Email: lstarr@dhs.state.ia.us
All application materials must be received by DHS by 4:30 p.m. on July 13, 2012.
Email submissions of all materials on the due date will be accepted, so long as there
is confirmation that originals have also been sent, and will be received by DHS by
July 16, 2012.
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Application Part A Fill out both columns.
Leave blank any information you do not want us to use to contact you:
Your Name:
____________________________________________
Agency name:
____________________________________________
Current status: (Check all that apply)
_____ I work here. ____I volunteer here. ____Other
Current job title:
____________________________________________
Work telephone: _______________________________
Work/volunteer address:
____________________________________________
____________________________________________
____________________________________________
Work e-mail: __________________________________
Best Time to Try:
____________________________________________
Home Address:
____________________________________________
____________________________________________
____________________________________________
Home Email: __________________________________
Home Telephone Number: _______________________
Cell Phone: ___________________________________
Street Address (if your home address is a P.O. Box):
____________________________________________
____________________________________________
____________________________________________
May we leave information regarding the status of your application with someone other than you?
If yes, complete:
Name:
____________________________________________
Phone:
____________________________________________
Please check the appropriate space.
Gender: _ Male _ Female
Are you 18 years of age or older? _ Yes _ No
Are you age sixty or older? (We hope to recruit older individuals in order to better serve older
populations) _ Yes _ No
Are you a person who currently accesses or has in the past accessed mental health services? _ Yes _ No
Are you completing Part A of the application yourself? _ Yes _ No
If not, please explain why and how you have been assisted in completing this application:
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide the name and organization of any person who has helped you complete the application:
_____________________________________________________________________________________
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What is the highest level of education you have completed?
__ 8th grade or less
__ Some High School
__ High School graduate or GED
Name and Location of High School:
____________________________________________________________
Year of Graduation:
________________________________________________________________________
Where GED was completed:
_________________________________________________________________
Year of Completion:
________________________________________________________________________
__ Some technical school or college
__ Technical school graduate or Associate Degree
__ College graduate
Name and Location of College or University:
_____________________________________________________
Year of Graduation: ________
Degree(s) awarded and area of study:
___________ __________________________________________
__ Postgraduate or professional degree
Name and Location of College or University:
_____________________________________________________
Year of Graduation: _________
Degree(s) awarded and area of study:
___________________________________________________________
Personal Commitment
The Iowa Peer Support Training Academy requires a significant commitment of time and energy. The
initial commitment involves a seven-day program (initial training of five days with a two day follow-up
with testing a couple of weeks later). Moreover, there is an expectation that you attend further meetings in
the future, engage in some form of advocacy activities, and provide updates and feedback on how you use
your training. Homework and activity reports will be required during the training. Please consider your
ability to commit time and energy to this project before applying.
Please initial each expectation as an indication that you understand and agree to these requirements:
____I understand that attendance at all sessions is mandatory. NO EXCEPTIIONS will be made.
____I commit to participate in the training to the fullest extent of my abilities.
____I commit to becoming actively engaged in mental health advocacy activities in my local community
and/or at the State level.
____I commit to maintaining contact with the Iowa Peer Support Training Academy and providing
feedback as requested, regarding how I use my training following completion of the training program.
____ I commit to the completion of all coursework, reading, and homework that is given to me
throughout the training.
____I understand that the Iowa Peer Support Training Academy is not a job placement program.
____I attest that all answers in this application are true to the best of my knowledge and that I have
completed this application myself (or have explained why I needed assistance above):
Signature and Date: _______________________________________________________
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Please indicate how many hours per month you are willing to commit to each of the
following:
____Becoming actively engaged in mental health advocacy activities in my local community and/or at the
state level (i.e. advisory committees for community mental health centers, local or state chapters of
mental health organizations, county CPC advisory committees, peer specialist organizations, legislative
forums, etc.)
____Maintaining contact with the Iowa Peer Support Training Academy and providing feedback as
requested (1 hour/month is recommended minimum)
____Pursuing available continuing education events and training (2 hours/month is recommended
minimum)
____Becoming involved in the Iowa Peer Support Training Academy (i.e. as an Advisory Committee
member, helping with the training in future years, assisting with the application and interview process in
future years)
Please provide some background regarding your computer skills:
Do you use email? _ Yes _ No
If no, will you commit to obtaining an email address before you begin the training? _ Yes_ No
Do you use the Internet to obtain information? _ Yes _ No
Please share any Special Dietary Needs (vegetarian, for example):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Application Part B Part B must be handwritten by the applicant, unless otherwise
explained above. Please answer each of the following questions that apply to you. If you need additional
space for your answers, please include attachments as necessary.
1. Specifically, why are you interested in the Iowa Peer Support Training Academy?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Please list what types of experiences you have had in communicating needs and
issues for persons with mental illness, substance abuse and/or other disabilities.
Please describe in detail your efforts such as letter-writing, speaking to service
providers or elected officials, speaking in front of a group, participation in
conferences, being an advocate, etc.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Please list relevant trainings you have attended, topics covered, approximate
dates, and who provided the trainings.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. What are your strengths and skills that you could utilize as a Peer Support
Specialist?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. Please describe what impact you want to make in your community.
________________________________________________________________________
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Describe your current employment situation (or volunteer situation). If neither
applies, how do you spend your time?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. What does recovery mean to you?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8. Are you completing Part B of the application yourself? _ Yes _ No
9. If not, please explain why and how you have been assisted in completing this
application:
________________________________________________________________________
_____________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
10. The cost of the Iowa Peer Support Training Academy is $950 per person to cover
training, food, and lodging. SCHOLARSHIPS WILL be available for some or
possibly, all attendees of this session of the Iowa Peer Support Training Academy.
The Academy will cap the training at twenty attendees.
I am unable to attend without a full scholarship: _____
I would need at least a partial scholarship in order to attend: ____
What agency or organization will provide the $950 registration fee?
10A. Please provide a letter of confirmation that the registration fee will be paid
from someone with authorization to make such commitment on behalf of the agency
or organization.
Please provide contact information for someone that IPSTA can contact with any
questions and to arrange payment?
Name: ________________________________________ Phone: __________________
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E-Mail: ________________________ Agency: _______________________________
Employment as a Peer Support Specialist
Preference will be given to persons who are currently employed or have an offer of employment in a peer
support position in the NE Iowa Crisis Stabilization project (NEIBH).
“Employment” for purposes of this application can include paid or volunteer work. Examples include
leading group support sessions, assisting in goal setting and recovery planning, or extending staff capacity
at drop-in and recovery centers. It should not be misinterpreted that only paid peer support positions will
meet this criterion; those who perform peer support in conjunction with a recognized group (for example,
the Veterans Administration or the local wellness center) but are not compensated may meet the
criterion, too.
Are you currently employed or volunteering in a peer support position or currently
providing services to individuals with serious mental illness? _ Yes _ No
If yes, please explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If no, have you received an offer of employment if trained? Please explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How do you plan to use the peer support training?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list contact information of your current or potential employer:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Something to consider is that mental health providers are required to conduct criminal background
checks, as well as dependent adult abuse and child abuse checks of their employees. People are not
necessarily disqualified from employment if they do have a criminal history or founded abuse, but if there
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are positive findings on the background check, there will be a further evaluation required before securing
employment. The Iowa Peer Support Training Academy would like applicants to be aware of this issue.
Application Review – Have you completed ALL parts of the application to the best of your ability?
___ Part A Completed?
___Part B Completed?
___TWO letters of support attached?
___Have authors of letters of support provided the 1-10 rating, and all of their contact information?
___Did you address funding, whether a scholarship will be needed, and whom to contact about any
funding they are offering for you?
___Any requested accommodations listed?
___Any special dietary needs listed?
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