1. Veterans’ Peer Support and the Criminal Justice System
Three-Day Forensic Training Application
November 16-18 2015
8:30am-4:30pm
*There is a cap of 25 attendees*
Location: OIM Training Center
123 Boro Line Rd
King of Prussia, PA 19406
This application is for the three-day Veterans’ Peer Support & Criminal Justice System
Training. Cost is $90.00 payable with application.
Please note: the three-day training is open only to Certified Peer Specialists who have served
in the military. By submitting this application, you are attesting that you are a certified peer
specialist and served in the military. Preference is given to Pennsylvania residents.
If you need accommodations to complete this application, contact PMHCA at
pmhca.@pmhca.org or call (717) 564-4930 or 1-800-887-6422.
Section 1: General Information
Name:
County:
Address:
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2. Section 1 continued
Email:
Phone number(s):
Current place of employment or volunteer work:
Job title (if applicable):
Preferred method of contact (circle or underline):
Email
Letter (postal mail)
Section 2: Knowledge & Experience
Please briefly answer the following questions.
Do you have experience with the criminal justice system? (As a mental health consumer, have
you yourself had contact with the criminal justice system?) What is your current involvement?
For example, do you serve on a county CJAB? Provide peer support to people who are
navigating the criminal justice system? Please explain to whatever degree you feel
comfortable.
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3. Section 2 continued
Does your county of residence have a Criminal Justice Advisory Board (CJAB)? If so, is there
mental health representation on the CJAB?
Please share your knowledge or experience of your county mental health system. (We ask this
so that you begin to think about how you will use the info in this training and what will you do
to bring the information you gain back to your county.)
Section 3: Interest & Involvement
Please briefly answer the following questions.
Why are you interested in attending the Peer Support & the Criminal Justice System Training?
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4. Section 3 continued
What is your experience in leadership roles, if any?
Section 4: Other Information
Do you need any special accommodations for the duration of the training (including linguistic
needs, dietary restrictions, access, etc)? If so, please list them here. (Note: this has no bearing
on the applicant selection process.)
Please list two emergency contacts (people we can call if you have an emergency occur during
the training):
1) Emergency Contact #1:
a. Name:
b. Relationship to you:
c. Phone number(s):
2) Emergency Contact #2:
a. Name:
b. Relationship to you:
c. Phone number(s):
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OMHSAS/PMHCA Veterans’ Forensic Peer Support Training November 2015

5. Please print your name, sign, and date. If sending by email, please just type/print your name
& fill in the date:
Printed name: _______________________________________________
Signature: ___________________________________________________
Date: ___________________
Please email (preferred), fax, or mail this completed application and a copy of your CPS
certificate to:
PMHCA
4105 Derry St.
Harrisburg, PA 17111
Email: pmhca@pmhca.org
Fax: 717-564-4708
Please note: All applications must be received by the end of the business day on October
30th, 2015 to be considered. If faxing your application, please write your name at the top of
each page and include a cover page, to ensure that your entire application is kept together.
*The training is co-sponsored by PMHCA and the Office of Mental Health and Substance Abuse
Services of the Pennsylvania Department of Human Services.*
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OMHSAS/PMHCA Veterans’ Forensic Peer Support Training November 2015

6. Please print your name, sign, and date. If sending by email, please just type/print your name
& fill in the date:
Printed name: _______________________________________________
Signature: ___________________________________________________
Date: ___________________
Please email (preferred), fax, or mail this completed application and a copy of your CPS
certificate to:
PMHCA
4105 Derry St.
Harrisburg, PA 17111
Email: pmhca@pmhca.org
Fax: 717-564-4708
Please note: All applications must be received by the end of the business day on October
30th, 2015 to be considered. If faxing your application, please write your name at the top of
each page and include a cover page, to ensure that your entire application is kept together.
*The training is co-sponsored by PMHCA and the Office of Mental Health and Substance Abuse
Services of the Pennsylvania Department of Human Services.*
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OMHSAS/PMHCA Veterans’ Forensic Peer Support Training November 2015