Form Test Medi-Cal Training Form Test Name(Required) First Last Date of Birth (MM-DD-YYYY)Email(Required) Phone / Cell(Required)Address (You must reside in California)(Required)Street, City, State, ZipCounty of Residence(Required)AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaAre you looking to become a Medi-Cal Certified Peer Support Specialist?(Required) Yes No Unsure How did you hear about the training?(Required) Parents Anonymous Parent Friend / Family / Coworker Website Social Media Advertisement Community Event Presentation / Webinar Other Are you looking to have Peer Training for your employees? Yes No Are you currently employed?(Required) Employed FT Employed PT Volunteer FT Volunteer PT Not Employed/Volunteerin I am employed – [check all that apply] in a Peer Support Role with a Behavioral Health County Agency with a Community Based Organization (CBO) with a Peer Run Organization at a Public Mental Health System (PMHS) Site If Other, type in answer below Other employed position, role, or entityDo you have a scholarship for this training? Yes No Please complete the following information about your employer.Company NameCompany AddressStreet, City, State, ZipContact or Supervisor NameContact or Supervisor TitleContact or Supervisor Email Contact or Supervisor PhoneAre there other employees in your Company that could benefit from this training Yes No Unsure How many other employees could benefit from this training? 0-2 3-5 6-9 10+ Will your Company pay for your training? Yes, in full Yes, a portion No Unsure Do you have a scholarship for this training Yes No What is the amount of the scholarship?If you need a scholarship, what is the amount you need to ensure you complete the training?Class Time FramesClass Time Frames You Prefer(Required) 4 Week Session – 4 hours a day, Monday through Friday – 9am to 1pm – Zoom 4 Week Session – 4 hours a day, Monday through Friday – 1pm to 5pm – Zoom 4 Week Session – 4 hours a day, Monday through Friday – 1:30pm to 5:30pm – Zoom 4 Week Session – 4 hours a day, Monday through Friday – 5:30pm to 9:30pm – Zoom Asynchronous – 30 days to complete training at your pace Hybrid – Monday & Wednesday on Zoom 5:30 pm – 9:30 pm, Tuesday, Thursday & Friday online Custom session for an organization. Minimum of 10. Online, In-person, or hybrid [check all that apply]Can you join one of these currently scheduled cohorts? 07/01/25 – 07/29/25 at 9:00 am – 1:00 pm with Trainer #1 Hybrid 07/01/25 – 07/29/25 Monday & Wednesday on Zoom 5:30pm – 9:30 pm; Tuesday, Thursday and Friday online Asynchronous 07/01/25 – 07/29/25 **Registration closes 5 days prior to the first day of training.** Please do not select a training session if it falls within the registration cutoff period. This allows you enough time to gather all the required documentation.Please upload the following documents here. Proof of Age (driver’s license, state ID, or birth certificate – you must be 18 years old before you take the State Certification Examination) Proof of Highest Level of Education (high school diploma or transcript, GED, or college diploma or transcript) Signed CalMHSA Medi-Cal Peer Support Specialist Certification – Code of Ethics Medi-Cal Peer Support Specialist Certification Training Policies and Procedures Note: If you are unable to upload them now, you must email them to training@parentsanonymous.org for the registration application to be complete. If you do not submit all the necessary documents by the first day of training, you will be dropped from that session and will need to wait for the next month’s training to begin. File Upload Drop files here or Select files Max. file size: 128 MB. Proof of Lived Expertise AND Statement of Willingness to Share Your Story(Required)By typing your name below, you acknowledge that you have read AND agree to follow the Parents Anonymous® Medi-Cal Peer Support Specialist Certification Training Policies and Procedures and CalMHSA Medi-Cal Peer Support Specialist Certification – Code of Ethics if you are accepted into this training. Please type your full legal name below to accept this Commitment and Acknowledgement and to complete the course Registration.Please type your full legal name below to accept this Commitment and Acknowledgement and to complete the course Registration.Today's Date(Required) Please Complete the Demographics SurveyPrimary Language(Required) English Spanish Both Other Other Languages spoken(Required) American Sign Language Arabic Armenian Cambodian Cantonese Chinese Farsi French German Haitian Creole Hebrew Hindi Hmong Italian Japanese Korean Khmer Kiswahili Laotian Mandarin Polish Portuguese Punjabi Russian Samoan Spanish Tagalog Thai Turkish Urhobo Vietnamese Other N/A Race/Ethnicity(Required) African American/Black African American Indian/Native American/Alaskan Native Cambodian Chinese Filipino Indian Japanese Laotian/Hmong Korean Pakistani Thai Vietnamese Caucasian/White/European Central American Cuban Mexican Puerto Rican South American Other Hispanic Middle Eastern Fijian Guamanian Hawaiian Samoan Tongan Other Pacific Islander Hispanic or Latino Non-Hispanic or Latino Unknown Decline to State Gender Identity(Required) Androgynous Female Female/Transwoman/MTF Transgender Male Male/Transman FTM Transgender Questioning my gender Non-Binary Other Decline to State Sexual Orientation(Required) Bisexual/Pansexual Straight/Heterosexual Gay Lesbian Questioning whether straight or not Queer Other Decline to state Unknown Age(Required)Consumer and/or Family Member(Required) Consumer Family member of consumers Caregivers of consumers None Unknown Decline to stat Veteran(Required) Yes No Unknown Disability(Required) Yes No Unknown Decline to state Have you ever been incarcerated?(Required) Yes No Decline to state Additional commentsCareer PlanTo expedite your registration process, please complete the Career Plan linked here. Don’t forget to return to this page to submit your registration.Additional CommentsAdd preference of days and/or times and any other detail not asked in the form.
