APPLICATION DEADLINE: April 1. Mental Health Program Educational Stipend Humboldt State University MSW Program

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1 Mental Health Program Educational Stipend Humboldt State University MSW Program Humboldt State University, in partnership with the California Social Work Education Center (CalSWEC) offers educational stipends of $18,500 per year for Concentration Year or Advanced Standing MSW students whose professional goal is to work in community mental health. Applicants must be in good academic standing in the MSW Program. Applicants interested in applying should demonstrate interest in and commitment to community mental health services as described in the Mental Health Services Act (MHSA). Mental Health Stipend (MHS) students are required to complete internships in a county mental health department in California, or a community agency contracted with the local county mental health department. For Humboldt County applicants, an in- person interview is required. In other counties, applicants will interview for the Mental Health Stipend Program via a conference call to include, the Mental Health Stipend Coordinator, the Field Director, and the potential supervisor identified by the applicant. Interviews take place in April for internships during the following academic year. Mental Health stipend students will also be expected to meet CalSWEC Mental Health stipend competencies. Upon completion of the MSW program the Mental Health stipend program graduate must work to complete a minimum of 12 months of employment with a program in county mental health or a community agency that has a contract with county mental health. The application is a two- part process involving both a written statement of interest and a personal interview. Completed applications include proof of legal residency in the U.S. and a valid California driver's license/state ID. Disbursement funds will be coordinated by CalSWEC program support staff. The likely process will be quarterly during the fiscal year. The initial stipend disbursement may occur after the semester begins so students should have other plans to pay for registration, books and living expenses. APPLICATION DEADLINE: April 1

2 MENTAL HEALTH STIPEND PROGRAM APPLICATION Please complete this application. Your application, brief essay, and interview responses will help us assess the knowledge, skills, and experiences that you might bring to the behavioral health field as an intern and future employee. STUDENT INFORMATION: Name Student ID# First Last Previous Social Security # Current Mailing Address Street Address City State Zip Phone Home Cell # Work # County of residence Contact information for three people who will always know how to reach you: 1. Name Address First Street Address Last City State Zip Phone Home/Work Cell #

3 2. Name Address First Street Address Last City State Zip Phone Home/Work Cell # 3. Name Address First Street Address Last City State Zip Phone Home/Work Cell # EDUCATION: DEGREE (BA, BS, BSW, Master's, Doctorate, etc.) Major/Field Institution Year you graduated

4 GPA in MSW program at the end of last term: Enrollment status in stipend year: Part- time Full time Expected date of graduation from MSW program: EMPLOYMENT: Please attach a copy of your resumé. Be sure that it includes the following information, if applicable: Ø Ø Ø Ø Current employment in a public mental/behavioral health agency (i.e. a county- operated or contract agency) that is not your placement Previous employment or volunteer experience in a public mental/behavioral health agency (i.e. a county- operated or contract agency) Previous employment or volunteer experience in a non- public mental/behavioral health agency, i.e. a nonprofit or for- profit agency that is not a county- contract agency Previous employment or volunteer experience in a health, social or other human service agency SUMMARY: Agency Experience Public/contract behavioral health agencies Non- public behavioral health agencies Other Health/Human Service Total Years DEMOGRAPHIC INFORMATION: GENDER: Female Male Other ETHNICITY: African American/Black Asian/Pacific Islander Caucasian/White Latino/Hispanic/Chicano Native American/Indian Other (please specify) Decline to state

5 LANGUAGE(s) in addition to English: Language A - Name: Proficiency Verbal Reading Writing Very Little Moderate ability Fluent Language B - Name: Proficiency Verbal Reading Writing Very Little Moderate ability Fluent Language C - Name: Proficiency Verbal Reading Writing Very Little Moderate ability Fluent Experience as a Consumer or Family Member Do you have experience with public or nonprofit behavioral health services as a consumer? Yes No Decline to State Do you have experience with public or nonprofit behavioral health services as a consumer's family member or caregiver? Yes No Decline to State

6 RESIDENCY: Country of Birth: Country of Citizenship: If foreign- born U.S. citizen, Date of Naturalization: If not a U.S. citizen, expiration date of legal documentation: If not a citizen, please provide a copy of your green card or other documentation. CRIMINAL BACKGROUND: If you have been convicted of a misdemeanor or felony in the last three years and you were over age 18 when convicted, please attach a separate sheet with date(s), charges, location(s) and penalties. You do not need to include offenses prior to your 18th birthday, any traffic violations with a fine of $ or less unless the traffic violation resulted in a felony or misdemeanor conviction, or expunged offenses. Description of convictions is attached Not applicable OTHER INFORMATION Do you have access to an automobile for placement- related travel? (Circle one): Yes No Driver s License Number: _ State: Driver s License Expiration Date: Do you have auto insurance? (Circle one): Yes No If Yes, name of company: Expiration Date:

7 PERSONAL STATEMENT Please answer the following questions in 3-6 pages. Reply to each question separately. You re statement should be in Times New Roman 12- point font, double- spaced with a header including your name and page number. Be very specific and clear in your answers. Attach your essay to the application form. 1.) Please describe past and current volunteer or paid work experience with mental health programs/populations. 2.) Describe your understanding of the Mental Health Services Act and its principles. Give an example or how you might apply one of these principles when working in a mental health setting. 3.) Share your interest in community mental health and your career goals. 4.) Discuss personal strengths and areas for personal development you might bring to the field of public mental health. 5.) Explain any personal/family issues (belief, time commitments) or circumstances that might be obstacles to successfully completing this demanding field placement or the 1- year work commitment after completing your MSW degree. 6.) The Mental Health Education Stipend Program is intended to increase the number of Master's level community Mental Health social workers. In particular, the program seeks to prepare graduates with multiple Mental Health competencies including implementation of the Mental Health Services Act, How do you see yourself being able to strengthen that goal? Attach personal statement and resume to completed application. Completed applications and supporting documents can be mailed to: Tina Georganas, Humboldt State University, Department of Social Work, 1 Harpst Street, Arcata, CA 95521, or delivered to her mailbox, BSS Building, Room 514. For questions, contact Margi Waller, MH Stipend Coordinator, margi.waller@humboldt.edu or (707) , or Tina Georganas, Administrative Support Assistant, tina.georganas@humboldt.edu or (707) APPLICATION DEADLINE: APRIL 1

8 AFFIRMATION & RELEASE OF INFORMATION: Please initial each statement indicating that you have read and agree to the following. I agree to complete my field placement in a public mental health agency and/or a community- based agency under contract to a county public mental health agency; I agree to have use of an automobile, a valid driver's license, and automobile insurance for bodily injury at all times during this program; I agree to be fingerprinted and to meet the criminal clearance requirements; I understand that I am obligated to pay back this stipend through one year of employment after completing my MSW degree in a county mental health agency, or a community- based organization under contract to a county public mental health agency for each year that I receive a mental health stipend. I hereby affirm that the above statements are true. I will agree to the provisions of the sample contract if granted a mental health stipend. Furthermore, I give the Awards Committee of the Mental Health Stipend Program permission to review my admissions application for entrance into the HSU Department of Social Work, MSW Degree Program. 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 code of ethics. Note: The criminal background clearance will disclose felonies and misdemeanors that may or may not disqualify you from employment in a county mental health agency or community- based organization under contract to county mental health. To be employed in mental health, you have to submit to a "live scan." If you have questions about this aspect of the eligibility criteria, please contact Margi Waller, Mental Health Coordinator, margi.waller@humboldt.edu. Signature: Print Name: Date: California Social Work Education Center Mental Health Stipend Program Humboldt State University