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TEST

Important Notice to Applicants
According to Missouri Credentialing Board (MCB) Policies and Procedures, the following rules apply to those seeking a MCB credential.
1. The following items disqualify an individual from obtaining the CPS with the MCB: A. Is listed on the Department of Mental Health disqualification registry B. Is listed on the employee disqualification list of the Dept. Health and Senior Services or Dept. of Social Services C. Any crime against a minor D. A person who has been convicted of, found guilty to, plead guilty to or nolo contendere to any of the Disqualifying Crime (s) Pursuant to Section 630.170, RSMo. The crime (s) will only disqualify an applicant if the crime (s) were a felony. Please view information about Section 630.170, RSMo on the MCB web site www.missouricb.com under the Disqualifying Crimes Link.
2. If an individual has applied for and been given an exception from the Department of Mental Health, the individual may apply for a MCB credential. Please send in proof of exception with your application.
3. If an individual will not be working in a Department of Mental Health certified agency and would still like to be credentialed, the individual may apply directly to the Missouri Credentialing Board exceptions committee.
Acknowledgement of MCB’s Policy and Procedures regarding obtaining an exception from either the Department of Mental Health or the Missouri Credentialing Board.*
- I acknowledge I have read and understand MCB’s Policy and Procedures regarding obtaining an exception from either the Department of Mental Health or the Missouri Credentialing Board. If I am denied an exception from either agency, I am not entitled to a refund, as the $75.00 fee was for the training and not the Certified Peer Specialist application.
Your Name*
First Middle Last
Your Email Address:*
Your Phone Number:*
Please list a number where we may contact you.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
1. List the county in which you reside.*
2019 CPS Basic Training Dates
Please select a training date preference below.
2. Which Training Date would you prefer?*
Please select a training date preference
- February 18-22 – St. Louis (E)
- March 11-15 – Columbia (C)
- April 8 – 12 – Kansas City (NW)
- May 6-10 – Cape Girardeau (SE)
- June 17-21 – Springfield (SW)
- July 8-12 – St. Louis (East)
- August 12-16 – Kansas City (NW)
- September 16-20 – Jefferson City (C)
- October 7-11 – Sikeston (SE)
- October 14-18 – Joplin (SW)
- November 18-22 – Kansas City (NW)
- December 2-6 – St. Louis (E)
3. Are you currently employed?*
- Yes
- No
4. List the last two jobs you have held, the name of your employers, and the dates of your employment.*
(Note: an employment history is not necessary for consideration.)
5. In order to attend this training you must have proof of a High School Equivalency (HSE) diploma or higher. Do you have a HSE or higher?*
- Yes
- No
If you do not have proof of a High School Equivalency (HSE) diploma or higher please contact the Missouri Credentialing Board, 573.616.2300, help@missouricb.com, for further assistance.
What is your highest level of education? Examples: High School Diploma, GED, Vocational Certificate (indicate specialty), Associate's Degree (indicate concentration), Bachelor's Degree (indicate major), Other (specify)*
6. Are you someone with lived experience with a behavioral health disorder? For purposes of this application, behavioral health disorder means mental health, substance use, or co-occurring disorder. (You must have lived experience with a behavioral health disorder.)*
- Yes
- No
If you do not have lived experience with a behavioral health disorder. please contact the Missouri Credentialing Board, 573.616.2300, help@missouricb.com, for further assistance.
7. What is your personal definition of recovery?*
8. Helping people in recovery can be very intense work. The core principle of peer support is sharing lived experience. Are you at a point in your recovery that qualifies you to use your personal experiences to help other individuals in their recovery journey?*
- Yes
- No
How do you know?*
9. Are you willing to disclose to peers, staff and the general public that you have lived experience with a behavioral health disorder?*
- Yes
- No
10. You will be expected to participate in discussions and role-plays using elements of your own recovery story. Are you comfortable sharing your recovery story with others during the training?*
- Yes
- No
11. You will also be required to listen to the recovery stories of others. Sometimes these stories may be uncomfortable for you, particularly if they touch upon one of your "triggers." Are you okay with this?*
- Yes
- No
12. The required training is intensive and can be fatiguing. Do you feel you generally have the energy to stay focused and alert?*
- Yes
- No
13. The training is highly interactive and requires activities that involve small groups, role-playing, and reading to the group. Are you comfortable with this kind of participation?*
- Yes
- No
14. Describe how your personal recovery journey has helped you to get where you are today.*
15. What are some of the things you do on a regular basis to keep yourself focused on your recovery?*
16. Describe at least two of your strengths and how they have helped you in your recovery.*
17. What is your plan to deal with triggers and/or a recurrence of your symptoms?*
18. Have you ever led a group?*
- Yes
- No
If yes, what did you like about it?*
If no, how do you feel about leading a group?*
19. Have you ever taught a class?*
- Yes
- No
If yes, what did you like about it?*
If no, how do you feel about teaching a class?*
20. Describe your best experience in employment, service work, or volunteer work and what made it meaningful.*
21. Describe your support system and how it has helped you in your recovery.*
22. Describe why you want to become a Certified Peer Specialist (CPS).*
23. Why do you believe you would be a good candidate to work with peers in the behavioral health disorder recovery field?*
24. Is there anything else you would like us to know?*
25. Have you ever applied and not been accepted to Certified Peer Specialist Training?*
- Yes
- No
IF the answer is yes, please list the year and location of that training.*
Test Monitor Information
Please provide a name, phone number and e-mail address of someone who will be able to serve in the capacity of a test monitor while you take the required online exam after you complete the training.
Test Monitor's Name*
Please do not put your name in this section.
First Last
Test Monitor's Phone Number*
Test Monitor's Email*
I consent to my submitted data being collected and stored*
- yes
CPS Participant Training Contract
CPS Participant Training Contract I understand that the CPS training is a professional training and that I will be held to professional training standards that have been set by the Missouri Credentialing Board. I further understand that if I do not adhere to the standards listed below I may be asked to leave the training by the instructor and no refund will be issued. Expectations for the Training
1. You must attend all training sessions. If an emergency arises you are allowed to miss up to three hours total. If you miss more than 3 hours, you are not eligible to receive a certificate of completion nor take the exam. (This includes reporting late, extra time out for breaks/lunches etc. Time away from the training is designed for emergency situations only and must have been approved by the trainers—this does not give you the ability to leave early from the training if you attended all week).
2. Actively engage in training sessions. Be alert and attentive to presenters and activities. Don’t be disruptive. Wait until after training sessions to have all non-training-related conversations. (If you are sleeping—you are not participating).
3. Be respectful and courteous in all presentations.
4. Turn off cell phones during presentations. Do not use telephones or text messaging during training sessions. (You will be able to check cell phones, emails, etc. during you hourly breaks or during lunch).
5. Turn off any personal music players, electronic organizers, and other electronic devices during presentations.
6. Personal Hygiene—During this training you are expected to always present yourself in a professional manner. It’s a large part of appropriate business conduct. The training rooms are often small and therefore be aware of others around you. Examples would include: daily baths or showers, using deodorant, hair-washing and avoiding offensive personal habits such as spitting and passing gas. Hand washing and the use of hand sanitizers has gained importance as a protection against the spread of illnesses. (If you do wear perfume, please insure that it is to a minimum as some attendees may have allegories to certain fragrances).
7. If the trainer believes your are under the influence of any substance you will be removed immediately from the training.
8. If you are removed from the training for any reason, your proctor will be notified by the Missouri Credentialing Board.
9. It is at the discretion of the trainers as to whether a attendee will be removed from the training and no refund will be issued by the Missouri Credentialing Board.
CPS Participant Training Contract
CPS Participant Training Contract I understand that the CPS training is a professional training and that I will be held to professional training standards that have been set by the Missouri Credentialing Board. I further understand that if I do not adhere to the standards listed below I may be asked to leave the training by the instructor and no refund will be issued. Expectations for the Training
1. You must attend all training sessions. If an emergency arises you are allowed to miss up to three hours total. If you miss more than 3 hours, you are not eligible to receive a certificate of completion nor take the exam. (This includes reporting late, extra time out for breaks/lunches etc. Time away from the training is designed for emergency situations only and must have been approved by the trainers—this does not give you the ability to leave early from the training if you attended all week).
2. Actively engage in training sessions. Be alert and attentive to presenters and activities. Don’t be disruptive. Wait until after training sessions to have all non-training-related conversations. (If you are sleeping—you are not participating).
3. Be respectful and courteous in all presentations.
4. Turn off cell phones during presentations. Do not use telephones or text messaging during training sessions. (You will be able to check cell phones, emails, etc. during you hourly breaks or during lunch).
5. Turn off any personal music players, electronic organizers, and other electronic devices during presentations.
6. Personal Hygiene—During this training you are expected to always present yourself in a professional manner. It’s a large part of appropriate business conduct. The training rooms are often small and therefore be aware of others around you. Examples would include: daily baths or showers, using deodorant, hair-washing and avoiding offensive personal habits such as spitting and passing gas. Hand washing and the use of hand sanitizers has gained importance as a protection against the spread of illnesses. (If you do wear perfume, please insure that it is to a minimum as some attendees may have allegories to certain fragrances).
7. If the trainer believes your are under the influence of any substance you will be removed immediately from the training.
8. If you are removed from the training for any reason, your proctor will be notified by the Missouri Credentialing Board.
9. It is at the discretion of the trainers as to whether a attendee will be removed from the training and no refund will be issued by the Missouri Credentialing Board.
CPS Participant Training Contract CPS Participant Training Contract I understand that the CPS training is a professional training and that I will be held to professional training standards that have been set by the Missouri Credentialing Board. I further understand that if I do not adhere to the standards listed below I may be asked to leave the training by the instructor and no refund will be issued. Expectations for the Training You must attend all training sessions. If an emergency arises you are allowed to miss up to three hours total. If you miss more than 3 hours, you are not eligible to receive a certificate of completion nor take the exam. (This includes reporting late, extra time out for breaks/lunches etc. Time away from the training is designed for emergency situations only and must have been approved by the trainers—this does not give you the ability to leave early from the training if you attended all week). Actively engage in training sessions. Be alert and attentive to presenters and activities. Don’t be disruptive. Wait until after training sessions to have all non-training-related conversations. (If you are sleeping—you are not participating). Be respectful and courteous in all presentations. Turn off cell phones during presentations. Do not use telephones or text messaging during training sessions. (You will be able to check cell phones, emails, etc. during you hourly breaks or during lunch). Turn off any personal music players, electronic organizers, and other electronic devices during presentations. Personal Hygiene—During this training you are expected to always present yourself in a professional manner. It’s a large part of appropriate business conduct. The training rooms are often small and therefore be aware of others around you. Examples would include: daily baths or showers, using deodorant, hair-washing and avoiding offensive personal habits such as spitting and passing gas. Hand washing and the use of hand sanitizers has gained importance as a protection against the spread of illnesses. (If you do wear perfume, please insure that it is to a minimum as some attendees may have allegories to certain fragrances). If the trainer believes your are under the influence of any substance you will be removed immediately from the training. If you are removed from the training for any reason, your proctor will be notified by the Missouri Credentialing Board. It is at the discretion of the trainers as to whether a attendee will be removed from the training and no refund will be issued by the Missouri Credentialing Board.
Signature
Signature*
My initial 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 my certification.
Payment Information
I acknowledge I have read and understand MCB’s Policy and Procedures regarding obtaining an exception from either the Department of Mental Health or the Missouri Credentialing Board. If I am denied an exception from either agency, I am not entitled to a refund, as the $75.00 fee was for the training and not the Certified Peer Specialist application.
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
CPS Training Application Fee*
- CPS Training Application Fee - $75
Total
$0.00

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TEST

Important Notice to Applicants

2019 CPS Basic Training Dates

Test Monitor Information

CPS Participant Training Contract

Signature

Payment Information

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