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NYCPS-Provisional Application Form

Please note that your information is saved on our server as you enter it.
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Welcome to the online New York Certified Peer Specialist-Provisional (NYCPS-P) application form.

This is a 9 page form created to gather all the information and documentation necessary for NYCPS-Provisional certification for review by the New York Peer Specialist Certification Board (NYPSCB).

To complete the application, you must start with page 1, ending with page 9 using the "next" button at the bottom.

You can go back to a completed page by clicking the "back" button or jump to a prior page using the progress bar at the top of the document.

We recognize it may take multiple sessions for you to complete this form, so there is a save-and-continue feature.

If you have already filled in your email below, when you click "save", the save-and-continue email field will autofill with that email address; otherwise, enter your email.

The save-and-continue button will give you 28 days to resume and complete your form.

If you saved to an email, please ensure you've received the email before closing the browser or tab. If you do not see the email, check your spam or junk folder.

If you lose that save-and-continue email, we have no way of providing lost pending form data and you'll have to re-enter your information.

Email(Required)
Name(Required)
Address(Required)
Max. file size: 100 MB.
Are you currently employed?

Please Provide Employment Details

Employer Business Address(Required)
Your Supervisor's Name(Required)
Is this work experience peer specialist specific?