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Texas Empowerment Initiative (TEI)
Advocating for Others
Registration Form
Please register below for the Texas Empowerment Initiative (TEI) Advocating for Others Training Course:
First Name
*
Middle initial
Last Name
*
Street Address
Address Line 2
City
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
County
*
Zip Code
*
Cell Phone
*
Home Phone
Email Address
*
🛈
Mailing address if different from above.
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Are you currently receiving mental health services or have you received them in the past?
*
Yes
No
Are you a family member of someone receiving mental health services, either now or in the past?
*
Yes
No
Are you currently receiving services from the public mental health system?
*
Yes
No
Not Sure
If you or your family member received public mental health services, were you or your family member given a copy of your rights and were they explained at the time of entering services?
Yes
No
Not sure
Have you had any advocacy training before?
Yes
No
Not sure
If so, please list:
If so, when and where?
How did you find out about this training?
Demographics (Optional)
Which gender do you identify with?
Male
Female
Other
Prefer not to answer
Age
18-25
26-35
36-45
46-55
56-65
Over 65
Prefer Not to Answer
Which of the following do you identify with?
(You may check more than one):
Heterosexual (straight)
Lesbian
Gay
Bisexual
Transgender
Prefer not to answer
Other - please specify:
Other - please specify:
Education (please mark the highest level received)
Less than a high school diploma
High school degree or equivalent (e.g. GED)
Some college, no degree
Associate degree (e.g. AA, AS)
Bachelor’s degree (e.g. BA, BS)
Master’s degree (e.g. MA, MS, MEd)
Professional degree (e.g. MD, DDS, DVM)
Doctorate (e.g. PhD, EdD)
Prefer not to answer
Income Range
Less than $6,000
$6,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
More than $75,000
Prefer not to answer
What is your current employment status?
Employed full time (30 or more hours per week)
Employed part time (up to 30 hours per week)
Unemployed and currently looking for work
Unemployed and not currently looking for work
Student
Retired
Homemaker
Self-employed
Volunteer
Unable to work
Prefer not to answer
Racial identity (You may check more than one):
White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Prefer not to answer
Other:
Other:
Hispanic/Latino/Spanish heritage
(You may check more than one)
Not Hispanic or Latino or Spanish
Mexican
Puerto Rican
Cuban
Central American
South American
Spanish
Prefer not to answer
Preferred Language:
English
Spanish
Prefer not to answer
Other, please specify:
Other, please specify:
Are you currently a Mental Health Peer Specialist (MHPS)?
Yes
No
If you work(ed) as a peer specialist, please tell us where you work(ed) (check all that apply):
State Hospital
Local Mental Health Authority (LMHA)
Local Behavioral Health Authority (LBHA)
Consumer Operated Service Provider (COSP)
Private Behavioral Health Provider
Other setting, Please specify
Other setting, Please specify
If you are not a Peer Specialist, have you considered becoming a Peer Specialist?
Yes
No
Prefer not to answer
If you are currently working in the mental health field and are not a peer specialist, what is your Profession/Job Title?
The Texas Empowerment Initiative (TEI) was developed by Austin Area Mental Health Consumers (AAMHC) and Prosumers International under grant number 1H79SM080857-01 from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.