Download APPLICATION FOR CalSWEC MENTAL HEALTH PROGRAM:

APPLICATION FOR L.A. COUNTY
DEPARTMENT OF MENTAL HEALTH STIPEND PROGRAM
2015–2016
Name: _______________________________________________________
Date: ________________
CSULB Student ID No.: _____________________ □ Female □ Male Birthdate: ________________
Social Work Program Model:
□ 2-Year
□ 3-Year
□ Advanced Standing
□ Integrated Health
□ CYF
□ OAF
□ Integrated Health
Address: _____________________________________________ County: _______________________
City: ________________________________________________ ZIP: _________________________
Primary Phone: ____________________________ Secondary Phone: ___________________________
Work Phone: ______________________________ Ethnicity: _________________________________
Primary E-Mail Address: _______________________________________________________________
Have you previously taken SW677 (Social Work Practice with Mental Health)?
□ Yes
□ No
Are you a U.S. Citizen? □ Yes
□ No
If “No,” attach a copy of your Permanent Resident “Green Card” (Exp. Date: ______________)
Language ability other than English (please specify language): ________________________________
Can you interview and conduct assessments in that language?
□ Yes
□ No
Can you provide therapy/counseling in that language?
□ Yes
□ No
Can you write reports in that language?
□ Yes
□ No
Are you familiar with the culture associated with that language?
□ Yes
□ No
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Application for LA County Department of Mental Health Stipend: 2015-2016
List any previous social work-related experience, including volunteer and internship, starting with most
recent, including agency name(s), job title(s), and length of employment. Be sure to indicate if this was
a mental health services-related experience. (Attach additional pages, if needed.)
FIRST YEAR OF INTERNSHIP
Agency: ____________________________________________________________________________
Job Title: ________________________________________
Full-Time: _____ Part-Time: _____
From: ____________ To: ___________
If part-time, hours per week: Internship: _____/Volunteer: ____
Duties/Responsibilities ________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------Agency: ____________________________________________________________________________
Job Title: ________________________________________
Full-Time: _____ Part-Time: _____
From: ____________ To: ___________
If part-time, hours per week: Internship: _____/Volunteer: ____
Duties/Responsibilities: ________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------Agency: ____________________________________________________________________________
Job Title: ________________________________________
Full-Time: _____ Part-Time: _____
From: ____________ To: ___________
If part-time, hours per week: Internship: _____/Volunteer: ____
Duties/Responsibilities: ________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------Agency: ____________________________________________________________________________
Job Title: ________________________________________
Full-Time: _____ Part-Time: _____
From: ____________ To: ___________
If part-time, hours per week: Internship: _____/Volunteer: ____
Duties/Responsibilities: ________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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Selection of Qualifying Criteria
To meet the objectives of the stipend program, the LAC DMH has identified the following needs as
priorities for workforce recruitment and will guide the selection of applicants for the stipends. Priority
One criteria address higher workforce needs than Priority Two criteria. Indicate with a check mark the
criteria for which you qualify. You may check all of the criteria for which you qualify.
Priority One: Language capacity and/or Multicultural competence
_____ I am applying for this stipend as a graduating student with multicultural or bilingual capacity and
am willing to commit to find employment at a DMH or DMH contracted agency, and able to provide
multiculturally competent services to consumers and/or services to consumers in one of the identified
threshold languages.
Priority One: Employment in “high need area or difficult to recruit program.”
_____ I am applying for this stipend as a graduating student and am willing to commit to find
employment in a DMH or DMH contracted agency, that provides services to consumers in the County’s
designated high need areas or difficult to recruit programs. These are identified as Service Area 1
(Antelope Valley), SA 4 (Downtown Los Angeles), SA 6 (South Los Angeles), SA 7 (East Los
Angeles), and services in Juvenile Justice Programs and jail system programs throughout the County.
Priority Two: Employment in “high need program”.
_____ I am applying as a graduating student for this stipend and am willing to commit to find employment in a DMH operated or DMH contracted agency, providing services to consumers in the County’s
designated high need program areas. These are identified as Specialized Foster Care (Katie A), Older
Adult Services, Veteran’s Services, and programs funded through MHSA that require in-the-field
services.
Priority Two: DMH Employment or Field Placement Experience.
_____ I have prior employment experience or placement training in a DMH or DMH contracted
agency. Indicate name of employment or placement agency below.
_________________________________________________________________________
Priority Two: Public Mental Health Experience, Training or Curriculum Specialization Serving
Veterans.
_____ I have prior experience, practicum training, or curriculum specialization serving veterans in
public mental health care. Indicate where experience, training or specialization took place:
_________________________________________________________________________
*Priority Two: Public Mental Health Experience, Training or Curriculum Specialization Serving
Older Adults.
_____ I have prior experience, placement training, or curriculum specialization serving older adults in
public mental health care. Indicate where experience, training or specialization took place:
_________________________________________________________________________
*Note: LAC DMH reserves the right to re-evaluate current workforce priorities and identify new
priorities during the term of the agreement.
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I understand that this award requires that I will complete all of the following requirements:

I will be accepted for internship for my second-year field placement at a stipend-eligible mental health
field internship agency;

I will successfully complete and receive a grade of CREDIT in my 2015-2016 field placement at a
stipend-eligible mental health field internship agency;

I will maintain enrollment in the MSW program, maintain a B (3.0) average, maintain adequate
automobile insurance while enrolled in the MSW program, complete a thesis/applied social work project
with an approved mental health focus; and will graduate in May 2016;

I will be able to successfully pass a Live Scan or other Department of Justice background check as
required to continue participation in this one-year program;

I will complete the required elective (SW677: Social Work Practice in Mental Health), and participate in
selected workshops and seminars on issues related to mental health and research;
Stipend Amount and Commitment
LAC DMH will be awarding educational stipends of $18,500 to eligible graduates. Stipend recipients
will need to be employed full time for one year in a public mental health agency, either directly operated
by or contracted with LAC DMH.
AFFIRMATION AND RELEASE OF INFORMATION
I give the LAC DMH Selection Committee permission to review my admission application and
associated materials for entrance into the California State University, Long Beach, MSW program.
I hereby attest that I have never been convicted of a felony crime or misdemeanor crime that would
disqualify me from service in a county mental health or county mental health-contracted agency.
I hereby attest that I have never been discharged from employment at a county mental health or county
mental health-contracted agency due to violation of county code/merit system rules or due to violation
of agency or professional codes or ethics.
___________________________________________________
Signature
Rev. 1.12.15
__________________
Date
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Application Essay Questions for LAC DMH Stipend Mental Health Program
2015–2016
Please respond to each of the following questions in a written essay format. Please label each question,
and then provide your response. Your essay paper (in response to all five items) should not exceed a
maximum of five (5) pages.
1) Describe the motivating factors for your interest in enrolling into the LAC DMH Program
as well as your commitment to the field of public mental health.
2) Describe recovery from mental illness using the Recovery Paradigm and how that
translates into your role as a social worker in the field of public mental health.
3) How do you envision using the skills and knowledge that you will learn in the LAC DMH
Program in your career as a social worker in the field of public mental health?
4) Describe in what ways you are similar to clients with whom you might work in the public
mental health field. How are you different?
5) Describe your own internal strengths and personal challenges and how they might impact
your work as a public mental health social worker?
THIS PROGRAM IS FOR CURRENTLY ENROLLED CSULB SCHOOL OF
SOCIAL WORK STUDENTS ONLY.
THE APPLICATION MUST BE SUBMITTED HARD COPY ONLY TO
DR. NANCY MEYER-ADAMS BY 5:00PM: MONDAY, JANUARY 26, 2015
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