NYCPS-Provisional Application Form

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)

Please provide us your email address. When you submit save this form and submit it, confirmation letters will be sent to this address. Please re-type your email again. It is important that this email is correct!

Name(Required)

Address(Required)

Phone(Required)

A State/Federal issued photo ID is required of certification. Please upload a legible copy (.pdf or .jpg format only)

Max. file size: 100 MB.

Are you currently employed?

Yes

No

Please Provide Employment Details

Your Job Title

Employer Business Name

Employer Business Address(Required)

Your Supervisor's Name(Required)

Supervisor's Phone

Supervisor's Email

Is this work experience peer specialist specific?

Yes

No

New York Certified Peer Specialist - Scope of Activities (2015)

The New York Peer Specialist Certification Board defines a NYCPS - New York Certified Peer Specialist as a person who, by virtue of special knowledge, training, and experience, is uniquely able to inform, motivate, guide, and support persons in recovery from a mental health condition, diagnosis or major life disruption.

In order to become certified as a NYCPS, a candidate must demonstrate they have completed appropriate education and training, relevant to the work of a peer specialist and endorse the NYPSCB Code of Ethical Conduct and Disciplinary Procedures.

For the purpose of certification, a New York Certified Peer Specialist is defined as a person who has demonstrated competence in performing a range of peer support activities as defined in the New York Certified Peer Specialist - Scope of Activities (2015). The scope of activities outlines the range of peer recovery services that a New York Certified Peer Specialist can provide to assist others in living their lives based on the principles of recovery and resiliency.

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

A. Understand and utilize specific interactions to assist peers in meeting their individualized recovery.
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.);
G. Appropriately document activities provided to peers in either their individual records or program records.

3. The New York 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 New York 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;
F. Assisting non-peer staff in a collaborative process in identifying programs and environments that are conducive to recovery.

In all activities, the peer specialist must demonstrate consistent adherence to the NYPSCB Code of Ethical Conduct (2015) & NYPSCB Code of Ethical Conduct – Disciplinary Procedures (2015) and agree to continue their professional development with ongoing education, training and maintain a working knowledge of current best practices and developments in the field of peer support.

Ethical Conduct and Permission to Obtain Information

Please read and sign at the bottom

A. I hereby attest that all of the information given is true and complete to the best of my knowledge and belief. I understand that falsification of any portion of this application will result in my being denied certification or revocation of same, upon discovery. I have read and understand the New York Peer Specialist - Scope of Activities (2015) and agree to abide by and operate within the Scope of Activities (2015) adopted by the NYPSCB.
B. I acknowledge the right of NYPSCB to verify the information in this application or to seek further information from employers, schools, or persons mentioned within.
C. I have read, understand, and agree to act in accordance with the NYPSCB Code of Ethical Conduct (2018) and the NYPSCB Code of Ethical Conduct – Disciplinary Procedures (2018) available on the NYPSCB’s website at http://www.nypeerspecialist.org/
D. I will hold NYPSCB, its Board members, officers, agents, and staff free from any civil liability for damages or complaints by reason of any action that is within their scope and arising out of the performance of their duties which they, or any of them, may take in connection with any examination, and/or failure of the Board to bestow upon me certification with the NYPSCB.
E. I understand that upon acceptance of my application, additional fees may be due and payable including exam fees, renewal fees, etc. and that all NYPSCB fees are non-refundable without exception.

Authorization to Obtain Information

I hereby authorize the NYPSCB to request and receive all records and/or information in any way relating to my application for a NYPSCB certification. I understand that this includes, but is not limited to, verbal or written contacts with my employer(s), colleagues, academic and training institutions, and/or other persons or organizations having pertinent information related to the review of my application. This is a waiver of my privilege that may otherwise exist in respect to the disclosure of such information. I understand that this authorization will expire one year after certification lapses or when my certification expires, once NYPSCB is notified of my intent not to renew. I further understand that the status of any NYPSCB certification is public record and may be shared by NYPSCB and is available on the NYPSCB website, including effective date, expiration date and certification type. I further understand that if my NYPSCB certification is sanctioned in any way including revocation or suspension that this information is public.

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Signature Authorization to Obtain Information(Required)

Date of authorization and attestation

Training Documentation - Academy of Peer Services (APS) Certificates

Upload APS Core Course certificates (13 required - see list) or the Core Courses Completion certificate (1)

Max. file size: 100 MB.

How many certificates did you upload?

Peer Specialist References

Please include the name and contact information for three references from individuals able to speak to your abilities as a peer specialist, using your recovery skills to support others. Letters should contain specific detail and description of your strengths, skills and abilities that will make you an effective peer specialist.

Please make sure to include the name, phone, email address and your relationship to the reference author.

The reference authors will receive an email with a link to send the NYPSCB a letter of reference on your behalf. However, you should email each reference author directly to notify them you have submitted their contact information to compete a letter and ask them to submit within 7 days to ensure prompt processing of your application.

Letters will not be accepted from:

1) Past or present clinical, medical, case management, or treatment providers

2) Family members

If you have any questions, please contact the NYPSCB office at info@nypeerspecialist.org for assistance with letter criteria or submission process.

Reference 1

Please provide reference information. An email will be sent upon final submittal requesting that the Reference Author fills in or uploads a letter of reference.

Name of Reference 1(Required)

Phone of Reference 1(Required)

Date you requested letter from reference author

Email of Reference 1

It is important that the email address is correct since an email will be sent upon final submittal Please re-type your email again. It is important that this email is correct!

Relationship to Reference 1 Author(Required)

Reference 2

Please provide reference information. An email will be sent upon final submittal requesting that the Reference Author fills in or uploads a letter of reference.

Name of Reference 2(Required)

Phone of Reference 2(Required)

Date you requested letter from reference author

Email of Reference 2

It is important that the email address is correct since an email will be sent upon final submittal Please re-type your email again. It is important that this email is correct!

Relantionship to Reference 2 Author(Required)

Reference 3

Please provide reference information. An email will be sent upon final submittal requesting that the Reference Author fills in or uploads a letter of reference.

Name of Reference 3(Required)

Phone of Reference 3(Required)

Date you requested letter from reference author

Email of Reference 3

It is important that the email address is correct since an email will be sent upon final submittal Please re-type your email again. It is important that this email is correct!

Relantionship to Reference 3 Author(Required)

Note: All 3 references are required.

High School Diploma or Equivalence Photocopy

Please scan and upload your high school diploma or equivalent document as a pdf.

How to Scan A Document

Once you have an image on your pc, click upload, navigate to your image and upload it.

I have my high school diploma.

Yes

No

Name of High School

Date of high school graduation

City and State of high school

If you did not obtain your high school diploma, please provide information about your high school equivalency. A high school diploma or equivalency is required in order to become certified.

I have obtained a high school equivalency (GED).

Yes

No

Please provide details about your high school equivalency

The certification board requires an image photocopy of your high school diploma or general equivalency document.

We prefer you upload a pdf. However, we only accept the following image types: jpg, tiff, gif, bmp, png or pdf.

There is a maximum size of 10MB for the image upload. Please consult your local library, office supply store or copy center and they can assist to make it smaller.

Upload Image of High School Diploma or GED(Required)

Accepted file types: jpg, tiff, gif, bmp, png, pdf, Max. file size: 10 MB.

Scan in your HS diploma or equivalent document and upload here.

Payment & Additional Documentation

Application Filling Fee NYCPS-P: $125.00

Upgrade Fee - NYCPS-P to NYCPS: $75.00

NYCPS-P Annual Renewal Fee: $60.00

NYCPS-P Two-Year Renewal Fee: $100.00

NYCPS-P Three-Year Renewal Fee: $125.00

IMPORTANT: A GRANT FROM THE OFFICE OF MENTAL HEALTH - NEW YORK IS CURRENTLY PAYING ALL CERTIFICATION FEES FOR ELIGIBLE CANDIDATES. If you live or work full-time in New York State, your certification fess will be paid in full from the OMH grant. All out of state applicants will be required to send payment to the NYPSCB office prior to the processing of their application.

Do you live in New York State?

Yes

No

Do you work in New Your State full-time?

Yes

No

If you DO NOT live or work in New York State, please email info@nypeerspecialist.org for details about submitting payment for your application as your application will not be reviewed until payment is received.

Additional Documentation

Type in any information you wish the board to consider regarding your application

0 of 500 max characters

Only 500 characters are permitted. If you have more detailed documentation, please upload a document or image below.

Would you like to upload any supporting documents or images?

Yes

No

Final Document Signature and Optional Survey

I affirm that all of the information contained in this application is true and correct to the best of my knowledge. I understand that knowingly providing false information may be grounds to deny or revoke my certification.

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Final Signature Attestation(Required)

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Would you like to fill out a quick survey?

Yes

No

Survey Question - Optional!

While we must request all the information for the review board, your feedback on this form is important to us.

Online Application

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NYCPS-Provisional Application Form

Please Provide Employment Details

New York Certified Peer Specialist - Scope of Activities (2015)

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

2. Utilizing direct peer-to-peer interaction and a goal-setting process, the New York Certified Peer Specialist shall:

3. The New York 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:

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

Ethical Conduct and Permission to Obtain Information

Authorization to Obtain Information

Peer Experience and Mental Health History Questions

NYCPS Training Modules

Training Documentation - Academy of Peer Services (APS) Certificates

Peer Specialist References

Reference 1

Reference 2

Reference 3

Note: All 3 references are required.

High School Diploma or Equivalence Photocopy

Please scan and upload your high school diploma or equivalent document as a pdf.

Payment & Additional Documentation

Application Filling Fee NYCPS-P: $125.00

Upgrade Fee - NYCPS-P to NYCPS: $75.00

NYCPS-P Annual Renewal Fee: $60.00

NYCPS-P Two-Year Renewal Fee: $100.00

NYCPS-P Three-Year Renewal Fee: $125.00

If you DO NOT live or work in New York State, please email info@nypeerspecialist.org for details about submitting payment for your application as your application will not be reviewed until payment is received.

Additional Documentation

Final Document Signature and Optional Survey

Survey Question - Optional!

Online Application

Save and Continue - If you used this feature

Thank you for providing feedback.