Eligibility Application for Family Peer Support Worker Certification

Program Requirements

By checking the boxes, you are verifying that you meet each requirement for the program.*

18 years of age or older
Valid New Mexico mailing address
Valid New Mexico Driver's License
High school diploma or GED
Parent or other family member (that has been the primary caregiver) of a child or youth that has received a mental health diagnosis or development disability with a co-occurring mental health diagnosis, and has navigated child serving systems on behalf of their child before the age of 18. **Child serving systems include mental health services, special education, juvenile justice, or child protective services.
May have familiarity or expertise in one or more child-serving system.

Contact Information

Name*

First Last

Address*

Street Address Apt/Unit/Suite City State Zip Code (ex. 88003)

County*

County in which you reside

Email*

Enter Email Confirm Email

Alternative Email*

Enter Email Confirm Email

Home Phone

Cell Phone*

Preferred phone number to set up interview*

Cell
Home

Primary Language*

Fluency in other Languages

Agency/Work*

If unemployed, enter "Unemployed."

Job Title*

If unemployed, enter "NA."

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Lived Experience

Please answer each question completely with at least 100 to 150 words per question.

Please describe your experience parenting a child/youth with emotional, behavioral or mental health challenges.*

Please describe any experience you have, including formal experience, of providing family peer services and support in helping others to navigate child serving systems.*

Please explain any concerns you have with sharing a personal story.*

Please explain why you want to become a Family Peer Support Worker.*

References

Please provide the names and contact information for two people who can verify your experience with your child, i.e., therapist, counselor, teacher, etc. Each reference will receive a notification for them to complete a reference form, please ensure you provide a valid, current email address for each reference.

Reference #1 Name*

First Last

Reference #1 Email

Phone Reference #1

Reference #2 Name*

First Last

Reference #2 Email

Phone Reference #2

How did you learn about this program?*

How did you learn about the opportunity to become a certified Family Peer Support Worker?

Affirmation

Your signature below affirms that you read and understand what is expected of all applicants, and the information you provided here is accurate otherwise, your application will not be considered.

Step 1. Check the box below.*

By checking this box and typing my name below, I am signing my application.

Step 2: Type in your name.*

First Middle Initial Last Suffix

Date*

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Training Calendar

Training Catalog

Eligibility Application for Family Peer Support Worker Certification

Program Requirements

Contact Information

Lived Experience

References

Affirmation

Contact

Mailing Address

Physical Address