MHA Peer Training Academy Application Peer Training Academy Online Application Legal Name (First & Last):(Required) First Last Suffix Preferred Name (First & Last): First Last Suffix Birth Date:(Required) MM slash DD slash YYYY Gender Identity (Please include pronouns):(Required) Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Daytime Phone Number:(Required)Email:(Required) Race:(Required) Ethnicity - please select one:HispanicNon-HispanicPrimary Language:(Required) Secondary Language: U.S.Citizen - please select one:(Required)YesNoReligion: Entitlements - please select all that apply: DHS/SNAP Medicaid SSI/SSD Unemployment Insurance Other Marital Status:(Required)SingleMarriedPartneredSeperatedDivorcedWidowedEducation - please select highest degree completed:(Required)High School DiplomaGED/TASCTradeCertificateAssociateBachelorMasterPh.D.Living Situation - please select all that apply:(Required) Alone/Independent Independent/With Housemates With Relative Supported Housing Insecure/Homeless Own Home Rent Apartment/House/other Community Living Do you participate in any other Mental Health Association programs?(Required)YesNoIf you answered Yes, please select the other Mental Health Association programs you participate in: CWO (Creative Wellness Opportunitues) Self-Help Drop-In Services Affinity Place Life Skills Basic Needs (benefits) Family Support Services Employment Services The Mental Health Association Peer Training Academy welcomes a diverse student roster with co-experiences - people with a mental health diagnosis who also have other lived experiences, such as military veterans, LGBTQIA+, incarceration, homelessness and/or substance use. This diversity of experience reflects the needs and perspective of mental health service users - the very people MHA graduates will be supporting in their work. It's important to us as a peer program that our classroom reflect the people we support. - Please answer the following questions as accurately and thoroughly as you can.(Required) I have read the above paragraph and agree to answer the following questions to the best of my ability. Incarceration - Have you experienced incarceration for more than 6 months?(Required)YesNoSubstance Use - Do you have alcohol/substance use recovery experience?(Required)YesNoHomelessness - Do you have homelessness experience?(Required)YesNoLGBTQ+ - Do you identify as a member of the LGBTQ+ community?(Required)YesNoMilitary Vet - Are you a military vet?(Required)YesNoAre you currently enrolled in ACCES-VR(Required)YesNoACCES-VR Information (formerly VESID)If you are not currently enrolled in ACCES-VR, were you ever?(Required)YesNoIf you were ever enrolled in ACCES-VR, but are not currently, please tell us the last year that you were enrolled: If you are currently or were ever enrolled in ACCES-VR, please give us the name of your ACCES-VR Counselor: Phone Number of ACCES-VR Counselor: Date of last contact with ACCES-VR Counselor: MM slash DD slash YYYY Has ACCES-VR sponsored you for other trainings?YesNoIf Yes, please list the trainings that ACCES-VR has sponsored you for: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.