Peer Supervisor
Application Form

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

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Preferred contact method *

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

Email Address *

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

Preferred Pronouns *

Date of the Training *

EXPERIENCE

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

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

Not Applicable

A QCC (Qualified Credentialed Counselor)

A LPHA (Licensed Practitioner of the Healing Arts)

A QMHP-CS (Qualified Mental Health Professional - Community Supervision), supervised under a QCC or LMHP

A QPS, supervised under a QCC or LMHP

If you are not sure, go to this link.

Are you a Qualified Peer Specialist (QPS), with a QCC or LPHA supervisor? *

Not Applicable

I have a GED or high school diploma, and at least four years of work experience as a certified peer specialist

I have an an associate degree or higher from an accredited university, and at least two years of experience as a certified peer specialist.

Attach supporting documents as required for your exerience level
2 letters of recommendation (required for all training options)
Documentation of QMHP designation with proof of supervision by a QCC or LPHA or
Documentation of 4 years work experience for Qaulified Peer Specialist (QPS) or
Documentation of college Degree iassociate or higher abd 2 years work experience for QPS or
Documentation of licnese for any pactioner of the healing arts.

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

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 must communicate an absence 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

Are there reasonable accommodations
for a disability needed? *

Yes

No

If Yes, Please explain

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 or substance
use recovery. *

Yes

No

NA

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. 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 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. 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. *

I acknowledge that I understand this policy.

Prosumers International reserves the right to decline registrations to any applicant that do not meet eligibility requirements. *

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

Peer Supervisor Application Form

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

Peer Supervisor
Application Form