Youth Peer Support Specialist Certification Application

"*" indicates required fields

Program Requirements

By checking the boxes, you are verifying that you meet each requirement for the program. Be prepared to provide documentation supporting these statements during the certification process.*

18 years of age or older

Have a valid NM ID

High school diploma or GED

Have personal experience, prior to the age of 18, navigating systems involvement in child welfare, juvenile justice, or children’s behavioral health OR have personal experience recovering from substance use or trauma that occurred prior to the age of 18

Have personal strategies used to maintain health and wellness and have been doing so for the past 2 years or more

Have a willingness and ability to share those strategies with others

High School Diploma or GED?*

Diploma

GED

HS Diploma

Optional-Download copy of High School Diploma if you have it

Max. file size: 100 MB.

High School*

Your High School Name

HS Location*

City, State for example, Hobbs, NM

Date HS Diploma or GED Obtained*

In Month, Year format for example, May, 1979

Contact Information

Name*

First Last

Valid NM ID*

Driver’s License

Other Valid NM ID

Valid NM ID #*

Valid New Mexico Driver’s License # or Other Valid New Mexico ID #

Valid NM ID Photo*

Upload a photo of your Valid NM ID

Max. file size: 100 MB.

Pronouns

He/Him

She/Her

They/Them

Other

Please indicate which pronouns you would like us to use if not listed above.

Age*

18-20

21-23

24-26

27+

Mailing Address*

NOTE: Please provide your current mailing address as it will be needed to send important training documents if you are accepted to be a Youth Peer Support Specialist Candidate. If your mailing address changes following your submission, please inform us so we can update our records.

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

Personal Email*

Enter Email Confirm Email

Work Email

Enter Email Confirm Email

Home Phone

Cell Phone*

Preferred phone number to set up eligibility interview*

Cell

Home

Primary Language*

Fluency in other Languages

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.

Why are you interested in becoming a Youth Peer Support Specialist?*

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

Are you currently connected to a Youth Serving Agency (school, community center, behavioral health provider, etc.) where you can complete the 40 hours of work exposure required for certification?*

Yes, I am connected to a youth serving agency where I can complete 40 hours of work exposure

No, I need to be connected with a youth serving agency where I can complete my 40 hours of work exposure

Name of Youth Serving Agency*

As part of the Youth Peer Support Specialist certification process, applicants must complete a 40 hour certification training on important topics related to professionalism, boundaries, ethics, personal wellness, and mental health. Accepted applicants will be notified about upcoming training dates. Please mark if you are able to meet the following training requirements:*

I will attend, be on time, and actively participate in the entire training, including keeping my camera on if the training is virtual. (Participants who have to miss part of the training will be asked to attend a future training).

I understand that I am not guaranteed employment or a volunteer position after attending this training.

If the training is virtual, I have regular access to the internet.

If the training is virtual, I have a reliable device (computer or phone) I can use to access the training.

If the training is virtual, I need support to access a reliable device to access the training.

Reference Letter

A reference letter can be provided by a mental health professional (school counselor/therapist), a supportive adult (must be a professional – not a friend or family member) who is familiar with your story and lived-experience, and/or a representative of a community organization that you are involved with (NOTE: this representative cannot be an individual affiliated with your current or planned Youth Serving Agency worksite). Please provide us with information to contact your chosen adult and then they will be sent a form to send back to us at their earliest convenience. This Reference Letter Form must be completed by your chosen adult before we can process your Youth Peer Support Specialist Certification Application. Please contact your chosen adult and ask them to watch for the email containing the Reference Letter Form link.

Reference Letter Name*

First Last

Reference Letter Email*

Reference Letter Phone Number

Hidden

Reference #2 Name

First Last

Hidden

Reference #2 Email

Hidden

Phone Reference #2

Do you wish to receive periodic news and updates from the Center of Innovation? You may opt-in to multiple email lists below.

Receive Newsletter/Updates*

Already Subscribed

Yes

Select list(s) to subscribe to:

CoI Newsletter

The Children’s Law Institute

Training & CEU Opportunities

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

Today's Date*

MM slash DD slash YYYY

Youth Peer Support Specialist Certification Application

Program Requirements

Contact Information

Lived Experience

Reference Letter

Do you wish to receive periodic news and updates from the Center of Innovation? You may opt-in to multiple email lists below.

Affirmation

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