Apply for Candidacy Step 1 of 4 25% Organization Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Primary Contact* First Last Primary Contact -Email* Enter Email Confirm Email Primary Contact – Phone*Sign up for CAPRSS eNewsletter Yes No Sign up for CAPRSS Virtual Learning Community Yes No Secondary Contact First Last Secondary Contact Email Secondary Contact Phone Which of the following best describes your organization?* Recovery Community Organization — Non Profit Recovery Community Organization — For Profit Treatment Organization — Non Profit Treatment Organization — For Profit How long has your organization been providing peer recovery support services?* Less than 2 years 2-5 years 5 + years What is your organization's mission statement?*Does your organization provide primarily*Mental Health Peer Recovery Support ServicesSubstance Use Peer Recovery Support ServicesBoth Mental Health and Substance Use Peer Recovery Support Services Peer Recovery Support Services (PRSS)Which of the following does your organization offer?* Select All Recovery planning Recovery coaching or mentoring Systems, services or resource navigation Support groups for individual recovery Support groups for family members Telephone-based recovery supports Recovery community center Health and wellness classes Life skills classes Please give a brief description of any additional supports/services you offer.Please list and describe other organizations with which you are affiliated or with which you have agreements/memoranda ofunderstanding to enhance, strengthen, or broaden your peer recovery support services.Are you part of a health home?* Yes No Where is the health home administratively housed?* Please list and describe any accreditations or certifications your organization currently holds.PRSS WorkforceWhat do you generally call all the individuals who are of service in your PRSS program?* Peer Specialists Peer Support Specialists Peer Recovery Coaches/ Mentors These individuals are…*Paid staffVolunteersBothHow many paid staff members does your PRSS program have?* How many of the paid staff are Full time?* How many of the paid staff are Part time?* How many unpaid individuals providing services do you have? Facilities and SitesAt how many sites that you own, rent, or manage do you offer peer recovery support services?* At how many "off-site" locations (community locations operated by other organizations or agencies) do you offer peer recoverysupport services? Budget and FinancesWhat is the current fiscal year budget for your whole organization?* What is your current fiscal year budget for your PRSS program?*
