1

Certified Peer Specialist Program

Application Process Checklist Complete and submit the checklist below to verify that all required documents are enclosed with the application prior to sending:

1. Completed Certified Peer Recovery Specialist Application YES NO

2. Recovery Narrative YES NO

3. Training Documentation YES NO

4. Employment/Volunteer Summary completed by applicant and supervisor YES NO (Not required if only seeking Provisional Certification)

5. Three completed Letters of Reference YES NO

6. Signed Scope of Activities and Code of Ethics Agreement YES NO

The above-completed checklist verifies that this application packet has been completed prior to its submission.

Your signature Date

Your printed name

For question please call (518) 426-0945

The completed application packet may be scanned and emailed to WDaniels@asapnys.org

Or sent via U.S. mail to:

New York Peer Specialist Certification Board

11 North Pearl Street

Suite 801

Albany, NY 12207

2

Office Use Only: Date Received Date Completed approved denied pending

1 - Certified Peer Specialist Application

Type or write legibly in only black or blue ink. Do not alter the application from its original format.

Name Date

Address

City, State, ZIP

Phone (with area code)

Email (required)

Last 4 Digits of Applicants Social Security Number

1. Certification requires a minimum of a high school diploma or a GED. Do you have a high school

diploma or GED? YES NO

2. Are you a current or former recipient of mental health or co-occurring services? YES NO

3. Are you currently hospitalized or under a court order that limits your decision making

authority?

4. Have you disclosed to peers, staff, or the general public your lived experience as a current or

former recipient of mental health or co-occurring services?

5. Are applying for a Provisional Certificate at this time? (If so please skip section 4 -

Employment/Volunteer summary)

YES NO

YES NO

YES NO

My signature below affirms that all of the information contained in this application is true and correct to

the best of my knowledge and has been completed by no other person. I understand that knowingly

providing false information shall be grounds to deny or revoke my certification.

Your signature____________________________________________ Date ______________

Your printed name __________________________________________________________________

3

2 - Certified Peer Specialist Recovery Narrative

1. Please give a brief description of your recovery journey: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

_________________________________________________________________________________________________________

2. Please give a brief description of the tools and activities you use to maintain your personal recovery: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

3. Briefly Describe how you utilize your personal experience of recovery to assist others in their recovery journey: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

4

3 - Certified Peer Specialist Training Documentation

I have completed training in the core competency areas as evidenced by passing the posttest for the following core courses from the Academy of Peer Services.

Action Planning for Prevention and Recovery

Creating Person-Centered Service Plans

Documentation for Peer Support Services

Essential Communication Skills (Active Listening and Reflective Responding)

Human and Patient Rights in New York

Introduction to Person-Centered Principles

Olmstead: The Continued Mandate of De-Institutionalization

Peer-Delivered Service Models

The Goal Is Recovery

The Historical Roots of the Peer Movement

The Importance of Advocacy & Advocacy Organizations

Trauma-Informed Peer Support

My signature below affirms that I have personal taken the test for these classes and achieved a passing score as

evidenced by obtaining a Certificate of Completion for each. I understand that knowingly providing false

information shall be grounds to deny or revoke my certification.

Your signature____________________________________________ Date ______________

Your printed name __________________________________________________________________

5

4 - Certified Peer Specialist Employment Summary

The applicant named below is applying for certification as a Peer Specialist with the New York Peer Specialist Certification Board. Peer Specialists, and their immediate supervisor should complete the following form regarding the applicant’s employment, work responsibilities and supervisory plan. Please provide a copy of this form for EACH position you wish to count toward the 2000 hours of practical experience

Applicant’s name

Title of applicant’s paid position

Has the applicant named above been employed to provide peer recovery services? YES NO

Date of employment providing peer recovery services

Number of hours assigned to provide peer support services per week

A Certified Peer Specialist should be under the supervision of a person with direct experience of providing peer to

peer services based on shared lived experience. If the supervisor does not have such experience, then please

indicate how such experience was incorporated into the supervision process (i.e. consulting peer specialist

supervisor training, etc.). Please provide the following information regarding the agency staff member who

provides direct supervision:

Supervisor’s Name Credentials

Title

Agency/Organization

Address

City, State, ZIP

Phone (with area code)

Email

How did the supervisor incorporate the lived experience view of peer support services into the supervision process?

Consulting Peer Specialist (Name)_______________________________________________________

Supervisor Training or experience (describe) ______________________________________________

Other______________________________________________________________________________

6

Indicate the activities of peer support services performed by the applicant within your agency/organization: (check all that apply)

Utilizing unique recovery experiences, the applicant performed which of the following:

Teach and model the value of every individual’s recovery experience;

Model effective coping techniques and self-help strategies; Encourage peers to develop a healthy independence; and Establish and maintain a peer relationship rather than a hierarchical relationship.

Utilizing direct peer-to-peer interaction and a goal-setting process, the applicant preformed which of the following:

Understand and utilize specific interactions to assist peers in meeting their individualized recovery goals;

Demonstrate and impart how to facilitate recovery dialogues through the use active listening and other best practice methods;

Demonstrate and impart relevant skills needed for self-management of symptoms, relapse;

Demonstrate and impart how to overcome personal fears, anxieties, urges, and triggers; Assist individuals in recovery in articulating their personal goals and objectives for recovery

Assist individuals in recovery in creating their personal recovery plans (e.g., WRAP®, crisis plan, etc.); and

Appropriately document activities provided to peers in either their individual records or program records.

The applicant did which of the following In order to maintain a working knowledge of current trends

and developments in the fields of mental health, substance use, co-occurring, and/or peer recovery services: Reading books, current journals, and other relevant material; Developing and sharing recovery-oriented material with other Certified Peer Specialists; Attending authorized or recognized seminars, workshops, and educational trainings.

The applicant served as a recovery agent by:

Providing and promoting recovery-based services (e.g., WRAP®, IPS, etc.); Assisting individuals in recovery in obtaining services that suit each peer’s individual recovery

needs;

Assisting individuals in recovery in developing empowerment skills through self-advocacy;

Assisting individuals in recovery in developing problem-solving skills so they can respond to challenges to their recovery;

When appropriate sharing his or her unique perspective on recovery from mental illness and co-occurring disorders with non-peer staff; and

Assisting non-peer staff in a collaborative process in identifying programs and environments that are conducive to recovery.

7

Indicate the scope of the supervision provided to the applicant. (check all that apply)

Weekly meeting Bi-weekly meeting Monthly meeting Individual meeting Group meeting

Indicate the nature of the supervision provided to the applicant. (check all that apply)

Debriefing on specific cases Administrative coordination Professional development Peer support skill coaching Mutually responsibly supervision

Indicate the Supervisor’s experience with peer support services

Previously provided direct peer support services

Yes No

Supervision of peer specialists (length of time)

None 1-3 years 3-5 years 5+ Years

My signature below affirms that all of the information contained in this document is true. Signature of Applicant ______________________________________________________Date ______________________

Signature of Immediate Supervisor ____________________________________________Date

8

4 - Certified Peer Specialist Volunteer Service Summary

The applicant named below is applying for certification as a Peer Specialist with the New York Peer Specialist Certification Board Peer Specialists, and their immediate supervisor should complete the following form regarding the applicant’s employment, work responsibilities and supervisory plan. Please provide a copy of this form for EACH position you wish to count toward the 2000 hours of practical experience

Applicant’s name

Title of applicant’s volunteer position (if applicable)

Has the applicant volunteered to provide peer recovery services with your organization? YES NO

Dates of volunteer service providing peer recovery services

Number of hours assigned to provide peer support services per week

A Certified Peer Specialist should be under the supervision of a person with direct experience of providing

peer to peer services based on shared lived experience. If the supervisor does not have such experience,

then please indicate how such experience was incorporated into the supervision process (i.e. consulting peer

specialist supervisor training). . Please provide the following information regarding the agency staff

member who provides direct supervision:

Supervisor’s Name Credentials

Title

Agency/Organization

Address

City, State, ZIP

Phone (with area code)

Email

How did the supervisor incorporate the lived experience view of peer support services into the supervision process?

Consulting Peer Specialist (Name)_______________________________________________________

Supervisor Training or experience (describe) ______________________________________________

Other______________________________________________________________________________

9

Indicate the activities of peer support services performed by the applicant within your agency/organization: (check all that apply)

Utilizing unique recovery experiences, the applicant performed which of the following:

Teach and model the value of every individual’s recovery experience;

Model effective coping techniques and self-help strategies; Encourage peers to develop a healthy independence; and Establish and maintain a peer relationship rather than a hierarchical relationship.

Utilizing direct peer-to-peer interaction and a goal-setting process, the applicant preformed which of the following:

Understand and utilize specific interactions to assist peers in meeting their individualized recovery goals;

Demonstrate and impart how to facilitate recovery dialogues through the use active listening and other best practice methods;

Demonstrate and impart relevant skills needed for self-management of symptoms, relapse;

Demonstrate and impart how to overcome personal fears, anxieties, urges, and triggers; Assist individuals in recovery in articulating their personal goals and objectives for recovery

Assist individuals in recovery in creating their personal recovery plans (e.g., WRAP®, crisis plan, etc.); and

Appropriately document activities provided to peers in either their individual records or program records.

The applicant did which of the following In order to maintain a working knowledge of current trends

and developments in the fields of mental health, substance use, co-occurring, and/or peer recovery services: Reading books, current journals, and other relevant material; Developing and sharing recovery-oriented material with other Certified Peer Specialists; Attending authorized or recognized seminars, workshops, and educational trainings.

The applicant served as a recovery agent by:

Providing and promoting recovery-based services (e.g., WRAP®, IPS, etc.); Assisting individuals in recovery in obtaining services that suit each peer’s individual recovery

needs;

Assisting individuals in recovery in developing empowerment skills through self-advocacy;

Assisting individuals in recovery in developing problem-solving skills so they can respond to challenges to their recovery;

When appropriate sharing his or her unique perspective on recovery from mental illness and co-occurring disorders with non-peer staff; and

Assisting non-peer staff in a collaborative process in identifying programs and environments that are conducive to recovery.

10

Indicate the scope of the supervision provided to the applicant. (check all that apply)

Weekly meeting Bi-weekly meeting Monthly meeting Individual meeting Group meeting

Indicate the nature of the supervision provided to the applicant. (check all that apply)

Debriefing on specific cases Administrative coordination Professional development Peer support skill coaching Mutually responsibly supervision

Indicate the Supervisor’s experience with peer support services

Previously provided direct peer support services

Yes No

Supervision of peer specialists (length of time)

None 1-3 years 3-5 years 5+ Years

My signature below affirms that all of the information contained in this document is true.

Signature of Applicant ______________________________________________________Date _________________ Signature of Immediate Supervisor ____________________________________________Date ______________

11

5 - Certified Peer Specialist Letter of Reference

References can be on this form OR on separate letterhead. Letters should be from someone who knows you well and can speak to your ability to use your experience in recovery to assist others. They can be from other peers, professionals, or person you know from the community. Letters cannot be from a member of your family or your current supervisor.

The applicant named below is applying for certification as a Certified Peer Specialist. You have been chosen by the applicant to provide a letter of reference. If you have questions, please contact the New York Certified Peer Specialist Board at (518) 426-0945 or WDaniels@asapnys.org.

Applicant’s name

Describe the nature of your relationship with the applicant and how long you have known him or her.

Describe the applicant’s activities (paid or volunteer) providing peer recovery services.

12

Describe your knowledge of the applicant’s strengths that will make the applicant a good candidate for becoming a

Certified Peer Specialist.

Provide any additional information pertinent to this applicant.

Reference Contact Information Name __________

Address

City, State, ZIP

Phone (with area code)

Email

My signature below affirms that all of the information contained in this document is true. Signature of Reference Date

13

6 - Certified Peer Specialist Scope of Activities

The scope of activities outlines the range of peer recovery services that a Certified Peer Specialist can provide to assist others in living their lives based on the principles of recovery and resiliency. Certification does not imply that

the Certified Peer Specialist is qualified to diagnose an illness, prescribe medication, or provide clinical services and

doing so constitutes at minimum a violation of the Certified Peer Specialist Code of Ethics. PLEASE DO NOT RETURN THE SCOPE OF ACTIVITES WITH YOUR APPLICATION. RETAIN THIS FOR YOUR RECORDS. SIGN AND RETURN THE

ACKNOWLEDGMENT ON PAGE 16.

1. Utilizing unique recovery experiences, the Certified Peer Specialist shall:

a. Teach and model the value of every individual’s recovery experience; b. Model effective coping techniques and self-help strategies; c. Encourage peers to develop a healthy independence; and

d. Establish and maintain a peer relationship rather than a hierarchical relationship.

2. Utilizing direct peer-to-peer interaction and a goal-setting process, the Certified Peer Specialist shall: a. Understand and utilize specific interactions to assist peers in meeting their individualized recovery

goals; b. Demonstrate and impart how to facilitate recovery dialogues through the use active listening and other

best practice methods; c. Demonstrate and impart relevant skills needed for self-management of symptoms, relapse;

d. Demonstrate and impart how to overcome personal fears, anxieties, urges, and triggers; e. Assist individuals in recovery in articulating their personal goals and objectives for recovery f. Assist individuals in recovery in creating their personal recovery plans (e.g., WRAP®, crisis plan, etc.); and g. Appropriately document activities provided to peers in either their individual records or program

records.

3. The Certified Peer Specialist shall maintain a working knowledge of current trends and developments in the

fields of mental health, substance use disorders, co-occurring disorders, and peer recovery services by: a. Reading books, current journals, and other relevant material; b. Developing and sharing recovery-oriented material with other Certified Peer Specialists; c. Attending authorized or recognized seminars, workshops, and educational trainings.

4. The Certified Peer Specialist shall serve as a recovery agent by:

a. Providing and promoting recovery-based services (e.g., WRAP®, IPS, etc.); b. Assisting individuals in recovery in obtaining services that suit each peer’s individual recovery needs; c. Assisting individuals in recovery in developing empowerment skills through self-advocacy; d. Assisting individuals in recovery in developing problem-solving skills so they can respond to challenges to

their recovery;

e. When appropriate sharing his or her unique perspective on recovery from mental illness and co-occurring disorders with non-peer staff; and

f. Assisting non-peer staff in a collaborative process in identifying programs and environments that are conducive to recovery.

14

6 - Certified Peer Specialist Code of Ethics

These principles will guide Certified Peer Specialists in the various roles, relationships, and levels of responsibility in which they function professionally. PLEASE DO NOT RETURN THE CODE OF ETHICS WITH YOUR APPLICATION. RETAIN THIS FOR YOUR RECORDS. SIGN AND RETURN THE ACKNOWLEDGMENT ON PAGE 16.

1. Certified Peer Specialists will at all times respect the rights and dignity of persons whom they assist with recovery and protect the welfare of all persons served by their agency by ensuring that nothing in their conduct constitutes physical or psychological abuse, neglect, or exploitation. Certified Peer Specialists will approach all interactions with persons whom they assist with recovery in a trauma informed manner.

2. Certified Peer Specialists will never intimidate, threaten, harass, use undue influence, physical force or verbal abuse, or make unwarranted promises of benefits to the persons they assist with recovery.

3. Certified Peer Specialists will not practice, condone, facilitate or collaborate in any form of discrimination on the basis of ethnicity, race, sex, sexual orientation, age, religion, national origin, marital status, political belief, disability, other preference or personal characteristic, condition or state, or any other category protected by state and/or federal civil rights laws. Certified Peer Specialists will maintain high standards of personal and professional conduct.

4. Certified Peer Specialists will advocate with persons whom they assist in recovery so that individuals may make their own decisions when partnering with professionals. Certified Peer Specialists are to be

knowledgeable of the tools used to achieve and promote the choices of the persons they assist with recovery.

5. Certified Peer Specialists will, at all times, promote the rights, dignity, privacy and confidentiality of persons

whom they assist in recovery. Certified Peer Specialists are to be knowledgeable of the importance of personal confidentiality, confidentiality of clinical records, and the procedure to help the persons whom they assist with recovery to access their clinical records.

6. Certified Peer Specialists have a duty to inform persons whom they assist in recovery, when first discussing

confidentiality, that threats of harm to self or others as well as allegations of abuse may not be kept confidential. Certified Peer Specialists have a duty to accurately inform persons whom they assist with recovery regarding the degree to which information will be shared with other team members, based on their agency policy and job description.

7. Certified Peer Specialists will keep current with emerging knowledge relevant to recovery, and openly share this knowledge with their coworkers and persons whom they assist with recovery. Certified Peer Specialists will refrain from sharing advice or opinions outside their scope of practice with persons they assist with recovery.

8. Certified Peer Specialists will not accept gifts of money or items of significant value from those they assist with recovery. Certified Peer Specialists do not loan or give money to persons they assist with recovery.

9. Certified Peer Specialists will utilize supervision and abide by the standards for supervision established by NYS OMH and/or their employer. The Peer Specialist will seek supervision to assist them in providing recovery oriented services to persons they assist with recovery.

15

10. Certified Peer Specialists shall only provide service and support within the hours, days and locations that are authorized by the agency with which they work.

11. Certified Peer Specialists will never engage in any sexual/intimate activities with persons whom they assist in recovery. Certified Peer Specialist will not enter into any relationship or commitment that conflicts with the interests of the persons they assist with recovery.

12. Certified Peer Specialists shall not abuse substances (including prescription medications) where it impedes their ability to assist others in recovery.

13. Certified Peer Specialists will be directed by the knowledge that all individuals have the right to live and function in the least restrictive and least intrusive environment, and promote and support services that foster full integration of individuals into the communities of their choice.

14. Certified Peer Specialists shall not offer services outside the boundaries of the Certified Peer Specialists competencies (including medication management) unless otherwise educated and trained, licensed or certified to do so.

16

6 - Acknowledgment of the Certified Peer Specialist Scope of Activities and Code of Ethics

By initialing and signing below, you understand that you are required to follow the professional standards of

conduct detailed in the Certified Peer Specialist Scope of Activities and the Code of Ethics. This includes all future

amendments and modifications thereto. Your initials and signature are required in this section.

By affixing my initials and signature below:

I acknowledge that I have received a copy of the most current Certified Peer Specialist Scope of Activities and the

Code of Ethics. I also will be responsible for obtaining all future amendments and modifications thereto.

Initials

I further acknowledge that I have read and understood all of my obligations, duties and responsibilities under each

principle and provision of the Certified Peer Specialist Scope of Activities and will read and understand all of my

obligations, duties and responsibilities under all future amendments and modifications to the Scope of Activities.

Initials

I further acknowledge that I have read and understood all of my obligations, duties and responsibilities under each

principle and provision of the Certified Peer Specialist Code of Ethics and will read and understand all of my

obligations, duties and responsibilities under all future amendments and modifications to the Code of Ethics. In the

event that an ethics complaint is filed against me, I understand that my certification may be suspended during the

investigation, depending on the severity of the complaint, as determined by the New York Peer Certification Board in

its sole discretion. If an ethics complaint against me is found to be substantiated, I further understand that my

certification may be revoked, depending on the severity of the violation, as determined by the New York Peer

Certification Board in its sole discretion.

Initials

Your signature Date

Your printed name