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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 Rev. 1.12.15 Page 1 of 5 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: ________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Rev. 1.12.15 Page 2 of 5 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. Rev. 1.12.15 Page 3 of 5 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 Page 4 of 5 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 Rev. 1.12.15 Page 5 of 5