CPRC Application : ICAADA

Have you completed either the CCAR 5-day training or the PEER Ethics training at any time prior to completing this application?

Section 1

Name *

First

Middle

Last

Pronouns *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Date of Birth *

Phone *

Email *

Highest Level of Education: (HS Diploma or equivalent at minimum is required) *

GED/HSE
High School Diploma
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate Degree

What is your primary language? *

Do you speak any additional languages? (If so, please list) *

Race (select all that apply) *

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black racial groups of Africa.
Hispanic, Latino or Latine. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Other. Race not listed
Prefer not to disclose

If you answered "Other. Race not listed" above, please fill in your race here.

Ethnicity *

Hispanic/Latino
Not Hispanic/Latino

Gender *

Agender
Female/Woman
Genderqueer
Gender Fluid
Gender Non-Conforming
Intergender
Intersex
Male/Man
Nonbinary
Other
Transgender
Trans Man/Male
Trans Woman/Female
I do not wish to provide this information

Are you a legal resident of Indiana? *

If no, do you work in Indiana at least 51% of the time? *

Section 2

Are you currently employed? *

If Yes, Who is your current employer? *

Position/Title *

Salary or Hourly Rate *

Which of these best describes the industry you currently work in? (Choose all that apply) *

Agricultural, farming, and natural resources
Architecture and construction
Arts, audio/visual technology, and communications
Business management and communications
Education and training
Finance
Government and public administration
Health science
Human Services
Information Technologies
Law, public safety, corrections, and security
Manufacturing
Marketing
Science, technology, engineering, and mathematics
Transportation, distribution, and logistics

Have you or a family member served in the U.S. Military? (Check all that apply) *

I have served in the military.
I have a family member who has served in the military.
None of the above.

Branch of Service *

Air Force
Army
Coast Guard
Marines
Navy
Not applicable

If you have served in the military, are you active/reserves or a veteran? *

Active
Reserves
Veteran
I have not personally served in the military

Section 3. Help us better understand who you are as a person.

Do you identify as a person in recovery from substance use? *

If yes, how long have you been in substance use recovery? *

Please share why you are interested in becoming a peer recovery coach. *

Have you ever been certified as a Peer Recovery Coach or other type of certified/licensed professional? *

What credential/license do you hold? (list all that apply) *

When did you initially obtain this credential/license? *

What agency/organization issued this credential/licensure? *

How many years of experience do you have working as a certified Peer Recovery Coach or other type of certified/licensed professional? *

Do you have experience working in a primary care setting? *

How many years' experience do you have working in a primary care setting? *

Do you have experience working in a behavioral health/mental health/substance use setting? *

Please select the field you have experience working in (select all that apply)

Behavioral Health
Mental Health
Substance Use

How many years of experience do you have working in the field(s) selected above? *

Do you have experience working alongside underserved/marginalized communities such as rural areas, racial/ethnic populations who do not represent the dominant culture, LGBTQIA+, lower socio-economic statuses, persons with disabilities? *

Please select the communities you have experience working alongside *

Rural areas
Racial/Ethnic populations who do not represent the dominant culture
LGBTQIA+
Lower socio-economic statuses
Persons with disabilities
Other

If you answered "Other" above, please explain

How did you hear about this PATCH Scholarship? *

E-mail message
Social Media
Friend
Co-worker
Flyer
Other

If you answered "Other" above, please explain. *

If you were referred by someone, please list their name and contact information. *

Section 4. Help us understand your career aspirations and goals?

How will the peer recovery coach credential you receive from this scholarship opportunity move you closer to your career aspirations or goals? *

Help us understand where you see yourself in your professional growth in one/five/ten years by earning this credential. *

Help us understand how obtaining the peer recovery coach credential will have a positive impact on the community where you will provide services. *

Help us understand why this financial assistance is requested. Please include a reasoning why you are unable to pay the fees yourself. *

Please share any potential barriers you see related to completing all required trainings and actions related to certification. *

Are you able to commit to the one full year of engagement with programming? *

Are you prepared to commit to the required full-time field placement within that year? *

Please list 2 personal and/or professional references that can attest to your character and recovery status (Name, email address, relationship with person) *

Please submit a copy of your government issued ID *

Click or drag a file to this area to upload.

Allowed file types: .png, .gif, .jpg

Section 5

I understand that a requirement of acceptance of the Peers Advancing Community Total Health (PATCH) scholarship, I must complete the following trainings and credentialing items:

1. Recovery Support Fundamentals: A Foundational Skills Based Approach (virtual training): 5-day, Monday-Friday course (9am-5:00pm)

2. Peer Recovery Ethics (virtual training): 2-day course held on consecutive days Monday - Friday (9am - 4:30pm)

3. HIV Education and Risk Reduction (virtual training): 1-day course held Monday - Friday (9am - 4:30pm)

4. Cultural Competency (virtual training): 1-day course held Monday - Friday (9am - 4:30pm)

5. Complete CAPRC application process that includes passing the IC&RC Peer Recovery exam.

6. Participation in monthly Continuing Education Webinars

Completion of this application does not constitute an agreement for scholarship award. Each application will be considered individually. The IAPRSS Peer Innovation Manager will notify you of your application status. If selected, you may be contacted for a phone interview.

I agree I have the means (time commitment, childcare, time off work etc.) to attend all the required training courses and complete all items related to certification.

Date *

Section 1

Section 2

Section 3. Help us better understand who you are as a person.

Section 4. Help us understand your career aspirations and goals?

Section 5

Earn credentials to treat and/or support individuals with behavioral health conditions.