518-426-0945

New York Certified Peer Specialist NYCPS Application

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Please clearly write or type all application forms
Name(Required)

Date of Application:

April 23, 2024

Date of Birth(Required)
Home Address(Required)
Employer Address(Required)

Please indicate below if you have a High School Diploma OR a GED/HS Equivalency:

I graduated from High School
MM slash DD slash YYYY
I obtained my GED/HS Equivalency
MM slash DD slash YYYY

Please make sure you complete all of the following items in order to ensure timely processing of your application. Your application will not be processed until you submit all of the following items:

  • Complete the entire NYCPS Application; fill-out, sign, and submit pages 1-8 of this packet

  • Submit an official transcript or verification of high school diploma or equivalent

  • N/A

    Enclose the application filing fee (ALL INITIAL FEES ARE CURRENTLY BEING FUNDED BY OMH)

  • Request three letters of reference be completed by individuals that can speak about your peer specialist abilities
    and have the forms mailed directly to the NYPSCB using the form provided on page 7 (make copies as needed)

  • Read and agree to abide by the NYPSCB Code of Ethical Conduct & Disciplinary Procedures

  • Submit a copy/photo of your current government-issued photo-id

  • Attach to page 4 a copy of all certificates of attendance or transcripts for training/educational events being applied
    toward certification requirements

  • Make a copy of the entire packet for your records prior to submitting to the NYPSCB.

Mail original and signed application packet to:

New York Peer Specialist Certification Board

3 Atrium Drive, Suite 205

Albany, New York 12205