MENTAL HEALTH TRAINING PROGRAM Funded by the Mental Health Services Act (MHSA) All sections must be completed or the application will not be reviewed

Transcription

1 MENTAL HEALTH TRAINING PROGRAM Funded by the Mental Health Services Act (MHSA) All sections must be completed or the application will not be reviewed Final Year Students admitted into the two, three or four year MSW program who will be completing their MSW - Advanced Field Practicum in Academic Year and who will graduate in Spring Final year students must be full time, taking 9 credits or more. We do not know if both clinical and admin/community development students are eligible for contract. Clinical will be eligible, admin/cd we are awaiting the new contract, to find out. Please apply using your name as it is listed with the University This application is in PDF format and the information will need to be handwritten. PLEASE WRITE ALL SECTIONS LEGIBLY. The essay question should be typed/word processed (NOT hand written) We have been asked to use this form by Calswec, so all applications will be identical and will collect the data that they need. Our apologies that it cannot be completed as a word document. Again, please print or capitalize - but write clearly. Please sign the application and submit it in its entirety, including a separate resume to the Mental Health Training Program, School of Social Work Office (HH 119) DEADLINE FOR SUBMITTING APPLICATION FRIDAY FEBRUARY 7th, 2016 BY 4:30 PM.

2 Mental Health Program Stipend Application Criminal Background If you have been convicted of a misdemeanor or felony in the last three years and you were over the age of 18 when convicted, please attach a separate sheet with date(s), charges, location(s) and penalties. You do not need to include offenses that occurred prior to your 18th birthday, traffic violations with fines of $ or less (unless the traffic violation resulted in a felony or misdemeanor conviction), or expunged offenses. Not Applicable Description Attached Driver s License and Insurance Driver s License Number: State Issued: Exp. Date: Automobile Insurance Company: Policy Number: Expiration Date:

3 STATEMENT ADDRESSING MENTAL HEALTH PRACTICE This statement will be utilized for evaluating your knowledge of mental health practice in California, current trends in the field, your awareness of the recovery model, and assessing your commitment to a career working in public mental health. There are no right or wrong answers, it is a matter of determining if this stipend program will be a good fit for you, and if you are motivated to pursue a career in public mental health. A maximum of 3-4 page paper, typewritten and double-spaced, is required. Please respond in a concise manner reflective of your knowledge and experience in the mental health arena. 1. This stipend program is funded by the Mental Health Services Act. (Also known as MHSA or Proposition 63) Briefly explain your understanding of the Mental Health Services Act and how it hopes to transform the delivery of mental health services in California. 2. Discuss your experiences, both personal and professional, that have prepared you for work in the mental health field. Do you have any experience with substance abuse treatment as well as mental illness? Explain why you wish to pursue a career in the public mental health, including your short and long term career goals. 3. Explain your understanding of the difference between The Medical Model vs. The Recovery Model or Psychosocial Rehabilitation when delivering mental health services. Why is a strengths based approach important? 4. Explain some of the barriers that individuals diagnosed with a serious mental illness face in obtaining treatment. Include some discussion regarding the impact of stigma regarding mental illness in our society. 5. Summarize what makes you a good candidate for this stipend program and how you will manage to balance academic demands, your internship, (employment, if applicable) and the additional requirements of the stipend program. What, if any, adjustments in your life, will you need to make? Thank you for your interest in San Diego State University, School of Social Work Mental Health Internship Program. If you have questions or additional concerns, please contact Candy Elson at: HH (619) or Candy.Elson@mail.sdsu.edu

4 Program Agreement for Mental Health Training Program Participation I understand that this award requires that I complete all of the following requirements: (1) Maintain good standing full-time enrollment in the MSW Program and complete the MSW curriculum. Good standing is defined as having a GPA of 3.00 or above. (2) Successfully complete and receive a grade of CREDIT in mental health field internship placement (3) Maintain automobile insurance while enrolled in internship in the MSW program (4) Complete required Specialized Mental Health Curriculum including: (1) SW702 Social Work Mental Health Policy (2) SW720 Psychopathology (3) SW781 Seminar: Psychosocial rehabilitation for individuals with serious mental illness (4) Mental Health Seminars and/or other training as required (5) Obligation to pay back this award is on a year per year basis. This requires a one (1) year, full-time employment commitment in a County or County contracted Mental Health program. I hereby attest that I have never been convicted of a felony crime or any crime involving harm to children. I hereby attest that I have never been discharged from employment at a county or other social services agency due to violation of county code/merit system rules or violation of agency or professional codes of ethics. Failure of any of the above stated requirements could result in a suspension of your payment of financial support. I hereby affirm that all information provided in this MSW Mental Health Training Program Application is true. Student Signature: Date:

5 Mental Health Program Stipend Application Personal Information First Name: Middle Initial: Last Name: Permanent Street Address: City: State: Zip: Mailing Address: City: State: Zip: Primary Phone: Alternate Phone: Primary MSW School: Date of Birth: / / Alternate School ID Number: Social Security Number: Previous Name(s) Used (if any): Gender: Female Male Transgender Other Ethnicity: American Indian/Alaskan Native Black/African-American/African Descent Caucasian/European Descent East Asian Hispanic/Latino Native Hawaiian/Pacific Islander Middle Eastern/Arab South Asian Multiracial (please specify) Marital Status: Single Married Separated Divorced Domestic Partner Widowed Annual Household Income: Are you a Veteran? Yes No Decline to state Do you self-identify as any of the following? LGBTQ Former Foster Youth Visibly or Invisibly Disabled Other Decline to state Do you have any personal experience as a consumer of behavioral health services? Yes No Decline to State Do you have any personal experience as the family member or caregiver of a consumer of behavioral health services? Yes No Decline to State

6 Citizenship and Residence History (all information will be kept strictly confidential) Country of Birth: Country of Citizenship: If a Naturalized U.S. Citizen, Date of Naturalization: / / If not a U.S. Citizen, Expiration Date of Green Card: / / or DACA: / / Current CA County of Residence: CA County of Residence prior to beginning MSW Degree: Education Degree (BA, BS, etc.) Major/Field Institution Graduation Year GPA in MSW program as of the end of last term: Enrollment status in MSW program in stipend year: Full-time Part-time Expected date of graduation from MSW program: / / Language Skills What is your first language? What languages do you speak, read, or write other than English? Language 1: Verbal proficiency: Very Little Moderate Fluent Reading proficiency: Very little Moderate Fluent Writing proficiency: Very little Moderate Fluent Language 2: Verbal proficiency: Very Little Moderate Fluent Reading proficiency: Very little Moderate Fluent Writing proficiency: Very little Moderate Fluent Employment and Volunteer Experience Are you currently employed in mental health, social services, or a related area? Yes No Employment Dates: From: / /

7 Is your current employment in a County or County-contracted mental health program? Yes No If YES, please provide the following information: I have attached a copy of Statement of Release for Academic Time I am currently seeking an educational leave from: / / to: / / Have you previously been employed in mental health, social services, or a related area? Yes No Employment Dates: From / / Employment Dates: From: / / Have you previously volunteered in mental health, social services, or a related area? Yes No Volunteer Dates: From / / Volunteer Dates: From: / / Please list any additional employment/volunteer experiences on a separate sheet of paper. How many years of experience do you have in the following work settings? County behavioral health agencies: years County-contracted behavioral health agencies: years Other health/human service agencies: years Please provide contact information for two people who will know how to reach you after graduation: Name: Name: Relationship: Relationship: Street Address: Street Address: City, State, Zip: City, State, Zip: Phone: Phone: Alternate Phone: Alternate Phone: I certify that all of the information provided here is true and accurate to the best of my knowledge. Signature / / Date