Adult PSS Personal Reference Form

ADULT PEER SUPPORT SPECIALIST REFERENCE FOR CERTIFICATION

You have been chosen by An applicant of The Training center’s adult peer support certification training to provide a reference for the purpose of verifying the individual’s demonstrated recovery from a mental health or substance use diagnosis. Please complete the reference form below and Submit. thank you!

the Applicant Must Possess, At A Minimum, A High School Diploma Or GED Equivalent And Meet The Following Criteria:

Have A Primary Diagnosis Of A Behavioral Health Disorder Which The Applicant Has Received Treatment And A Strong Desire To Identify Themselves As A Person With A Behavioral Health Disorder (Current Or Former Consumer Of Behavioral Health Services Including Substance Abuse Treatment).
Demonstrate Strong Reading Comprehension And Written Communication Skills As Indicated By Their Responses On The Short- Essay Form.
Demonstrated Experience With Leadership And Advocacy In The Field Of Behavioral Health/ Substance Use Disorders; As Well As The Ability To Demonstrate His Or Her Own Efforts At Self- Directed Recovery.

NAME OF THE APPLICANT FOR WHICH YOU ARE THE REFERENCE

First Name

Last Name

I AM AWARE THE APPLICANT HAS A MENTAL HEALTH OR SUBSTANCE USE DIAGNOSIS AND HAS SUSTAINED A PATTERN OF RECOVERY FROM SAID DIAGNOSIS

PLEASE DESCRIBE THE NATURE OF YOU RELATIONSHIP WITH THE APPLICANT

DESCRIBE YOUR EXPERIENCE WITH THE INDIVIDUAL THAT INDICATES HIS/HER DEMONSTRATED SUSTAINED RECOVERY

PLEASE INDICATE ANY STRENGTHS OR ASSETS THIS INDIVIDUAL MAY OFFER AS A PEER SUPPORT SPECIALIST.

NAME OF REFERENCE

DATE

REFERENCE PHONE

REFERENCE EMAIL

THANK YOU FOR YOUR ASSESSMENT OF THIS INDIVIDUAL AS A PEER SUPPORT CANDIDATE. THE STATE REQUIRES OUR AGENCY TO CONTACT EACH PARTICIPANT'S REFERENCE AS PART OF THE ADMISSION PROCESS. THE CALL WILL COME FROM THE FOLLOWING NUMBER 5023708781. THANKS AGAIN!

Adult PSS Personal Reference Form

ADULT PEER SUPPORT SPECIALIST REFERENCE FOR CERTIFICATION

the Applicant Must Possess, At A Minimum, A High School Diploma Or GED Equivalent And Meet The Following Criteria:

Have A Primary Diagnosis Of A Behavioral Health Disorder Which The Applicant Has Received Treatment And A Strong Desire To Identify Themselves As A Person With A Behavioral Health Disorder (Current Or Former Consumer Of Behavioral Health Services Including Substance Abuse Treatment).

Demonstrate Strong Reading Comprehension And Written Communication Skills As Indicated By Their Responses On The Short- Essay Form.

Demonstrated Experience With Leadership And Advocacy In The Field Of Behavioral Health/ Substance Use Disorders; As Well As The Ability To Demonstrate His Or Her Own Efforts At Self- Directed Recovery.