Verification Form

This form should be filled out by the supervisor or other qualified individual who oversaw the exposure hours for a family peer support worker candidate.
  • This is the name of the supervisor or other qualified individual who oversaw the hours of a family peer support worker candidate.
  • Supervisor's email
  • Supervisor's phone
  • Supervisor's title
  • Please provide the name of the program where the hours were completed
  • Candidates should complete 40 hours total. Hours may be completed at the same site or multiple sites. Please enter the number of hours completed in your program.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please provide a general description of the activities completed and type of experiences the candidate participated in.
  • Applicant Exposed to Following Activities in this Agency:

  • During the work exposure the applicant exhibited the following skills or professional traits:

  • Do you have any concerns with this candidate completing certification as a Family Peer Support Worker and beginning working direction with parents and other caregivers. Do you recommend this candidate?

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