Qualified Peer Coordinator (QPC) 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 church affiliate Referral from a mental health professional Self-Referral None of the above/Other PSS and Site Affiliation * Please indicate below who will be your Peer Support Specialist (PSS) 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 submitting your QPC self-registration form. We will be in contact with you shortly to confirm the submitted documents. The program will officially launch with a dually executed agreement. For questions or concerns, please contact director@apostlesoflife.org
