CORE
Application Form

For people working at a LMHA/LBHA, ther is a 10% discount available. You must register with your LMHA/LBHA email address.

If you are applying to be a PSS, please go to this application link.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

If your address changes before training, please let us know, as your materials will be sent to the address provided here.

Phone Number *

Preferred contact method *

Email Address *

All communication regarding this training will be provided to the contact information you provide here.

Preferred Pronouns *

Which Training are you applying for? Check only one. If you want additional, please fill out another application. *

Core Training $250

What Date Training do you want to take? *

Do you need a full or partial scholarship?
These are limited and on a needs basis only. *

Candidate Eligibility Checklist:

I have read the
application supplement. *

Yes

No

I am 18 years or older. *

Yes

No

I have a history
Of Justice
Involvement. *

Yes

No

I have a High School Diploma or GED. (If you apply for certification following the training, you will be required to provide documentation of a minimum education level of a high school diploma, GED or highest level obtained.) *

Yes

No

I certify that no one completed
this application form for me. *

Yes

No

I identify myself as a person who has
personal lived experience
with mental health recovery. *

Yes

No

I agree to disclose my personal lived
experience as it relates to mental
health for the purpose of educating,
role modeling and providing hope
to others about the reality of recovery. *

Yes

No

I have lived experience with mental
health recovery or a co-occurring
disorder, rather than a
substance use diagnosis only. *

Yes

No

You must anwer yes to all of the above to proceed. If you have special circumstances that you would like to discuss with Prousmers International, please contact Adriana Barbosa at adrianab@theprosumers.org.

Attach supporting documents as required for your specific training.
2 letters of recommendation (required for all training options)
Attestation of Completed Self-assessment and Orientation (for people applying for Core Training)

RECOVERY EXPERIENCE

Do you currently hold a peer support position
(paid or volunteer) and expect to do the work of a
Mental Health Peer Specialist following this training? *

Yes

No

Select all Peer certifications you currently have in Texas? (Check all that apply)* *

What is your concept of recovery and what does it mean to you *

What is your concept of the role of a MHPS and why do you want to be one?* *

What things do you do to maintain your wellness?* *

Participation Requirements Checklist

I will attend and actively participate in all of the training days and activities. *

Yes

No

I will confirm in advance with both Prosumers and the trainers if I need to be absent for part of the training. *

Yes

No

I understand that 10% of the stated training
time is the maximum I can be absent for
legitimate emergency situations. *

Yes

No

I must communicate an absense to both trainer and Prosumers Office Support Staff as soon as possible or I may not be eligible to complete the training and sit for the certification exam. *

Yes

No

I will participate in discussion and
role-plays utilizing my personal
experiences and sharing my
mental health recovery story. *

Yes

No

I acknowledge that Prosumers may take photographs
during the training for inclusion in any and all of its
publications, including social media. If I do not wish
to be included, I will notify Prosumers before the
start of training. *

Yes

No

I understand that I am not guaranteed
employment or a volunteer position
as a result of participating in this training. *

Yes

No

I agree to take the knowledge
assessment following the Core
and Supplemental training. *

Yes

No

Are there reasonable accommodations
for a disability needed? *

Yes

No

If Yes, Please explain

Demographics (optional)

By answering the demographics, it allows us to seek funding to reduce the price of traiing.

Gender

Age

18-25

26-35

36-55

Over 55

Race/Ethnicity: Check all that apply.

Are you either an Active Member or Veteran in the Armed Forces?

Yes

No

Acknowledgements

Applicants acknowledge that if the training is offered online, they have a device with access to a video camera, stable internet, speakers or headset and mic to participate in the online training *Applicants must meet the technology requirements to participate in the training. *

Yes

No

Applicants agree to attend the entire training and actively participate including, but not limited to class discussions, group activities, roles plays, homework etc. *

Yes

No

Applicants acknowledge that after successfully completing the training they must take a knowledge assessment and pass with a score of 70% or greater. Applicants that do not pass the knowledge assessment will be allowed to retake the assessment a total of 2 times. After the second attempt if the participant does not pass the knowledge assessment they will be required to retake the training. *

Yes

No

Applicants understand that completing this training does not guarantee employment or a volunteer position with any agency/organization. *

Yes

No

Refund Policy: Prosumers do not provide refunds. Applicants may request to apply the amount they have paid to a future training by emailing Prosumers International at info@theProsumers.org or calling 800-577-9735. Applicants will receive a credit equal to the amount they have paid, which can be applied to any future training date within 1 year of original purchase. Purchase credits not applied within 1 year will be forfeited. *

I acknowledge that I understand this policy.

Prosumers International reserves the right to decline registrations that do not meet eligibility requirements or constitutes a risk. *

I acknowledge that I understand this policy.

Payment policy: a payment link will be sent upon approval of the application. Payment must be made prior to coming to the course. If payment is not received or arrangements have not been made within 24 hours of the course beginning, the Participant will not be allowed in the course. *

I acknowledge that I understand this policy.

By selecting accept I am acknowledging that I have read and understand the terms and condition. *

I accept

I don't accept

Your Signature *

clear

Date of Submission * +

Thank you for your application. Once you have been accepted you will be sent a link to pay for the course. If you have any additional questions, contact Prosumers International at 1-800-577-3795

For Internal Use ONLY Comments

CORE Application Form

Candidate Eligibility Checklist:

RECOVERY EXPERIENCE

Participation Requirements Checklist

Demographics (optional)

Acknowledgements

Thank you for your application. Once you have been accepted you will be sent a link to pay for the course. If you have any additional questions, contact Prosumers International at 1-800-577-3795

CORE
Application Form