Advanced/Specialized Coaching Academy Training Application Name(Required) First Last Email(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 Phone(Required)What best describes you?(Required) Woman Man Transgender Nonbinary No Answer Other Mark only one oval.What best describes you?(Required) Black/African American Native American Hispanic/Latinx Asian/Pacific Islander White No Answer Other: Mark only one oval.Are you a Recovery Court (ACDC, HEALS), DUI Court, DV Court, or Veterans Trauma Court graduate or participant?(Required) Yes No Mark only one oval.Are you an FTDC Graduate or Participant?(Required) Yes No Check all that apply.If you answered yes to either of the previous questions, what phase are you in? Are or were you involved in Corrections?(Required) Yes No Mark only one oval.Have you ever been hospitalized due to substance use disorder?(Required) Yes No Mark only one oval.Have you ever served in the military?(Required) Yes No Mark only one oval.Are you receiving SNAP benefits?(Required) Yes No Check all that applyHow did you hear about the training academy?(Required)Please explain your knowledge or expectations of peer recovery coaching.(Required)What class from the Peer Recovery Coach Training Academy catalog are you interested in taking?Are you able to fully commit to the training? (ample bandwidth to be on zoom if training virtually and personally) Class requires attention and participation.(Required) Section BreakPLEASE ANSWER THE FOLLOWING 10 QUESTIONS AS HONESTLY AS POSSIBLE. BRIEF ASSESSMENT OF RECOVERY CAPITAL Instructions: On a scale of 1 (Strongly disagree) to 6 (Strongly agree), please indicate your level of agreement with the following statements. 1. There are more important things to me in life than using substances.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree2. In general I am happy with my life.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree3. I have enough energy to complete the tasks I set myself.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree4. I am proud of the community I live in and feel part of it.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree5. I get lots of support from friends.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree6. I regard my life as challenging and fulfilling without the need for using drugs or alcohol.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree7. My living space has helped to drive my recovery journey.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree8. I take full responsibility for my actions.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree9. I am happy dealing with a range of professional people.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agree10. I am making good progress on my recovery journey.(Required) 1 2 3 4 5 6 Mark only one oval 1= strongly disagree - 6 strongly agreePlease explain your training and work experience as it pertains to peer recovery coaching.(Required)If you are requesting financial assistance, please summarize your needs.We are all recovering from something. How do you take care of yourself and your recovery?(Required)I acknowledge SRC's nonprofit status and limited resources. I understand scholarships are not guaranteed, and I may be asked to find alternate funding for my training.(Required) Yes No Mark only one oval.
