Peer Support Specialist (PSS)Self-Registration FormFill out the form below and we will be in touch! Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * How did you hear about us? * Referral from a peer Referral from a mental health professional Referral from a church affiliate Self-referral None of the above/Other QPC and Site Affiliation * Please indicate below who will be your Qualified Peer Coordinator (QPC) and to which Site will you be affiliated. Program Evaluation and Implementation (PEI) Manual? Please indicate below if you have read the PEI Manual. Yes, I have read the manual. No, I have not read the manual. Thank you for your PSS Self-Registration. We will be in contact with you shortly regarding the verification documents to officially begin the program. For questions or concerns, please contact director@apostlesoflife.org
