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 2016-2017 and who will graduate in Spring 2017. 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 2016-17 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.
DEADLINE FOR SUBMITTING APPLICATION – FRIDAY FEBRUARY 7th, 2016 BY 4:30 PM.
http://socialwork.sdsu.edu/degrees-programs/graduate-programs/mental-health-training-program/
MENTAL HEALTH TRAINING PROGRAM
Funded by the Mental Health Services Act (MHSA)
All sections must be completed or
the application will not be reviewed
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)
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 $500.00 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: ____________________________________________________________
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 117 - (619) 594-5144 or Candy.Elson@mail.sdsu.edu
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.
Personal Information
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
First Name: Middle Initial: Last Name:
Permanent Street Address: City: State: Zip:
Mailing Address: City: State: Zip:
Primary Phone: Alternate Phone:
Primary Email: Alternate Email:
MSW School: School ID Number:
Date of Birth:
____ / ____ / _____
Social Security Number:
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 lastterm: _____________________
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
Agency:
Department/Unit: Job Title:
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
Agency: Department/Unit:
Job Title:
Employment Dates: From _____ / _____ / _______ To: _____ / _____ / _______
Agency: Department/Unit:
Job Title:
Employment Dates: From: _____ / _____ / _______ To: _____ / _____ / _______
Have you previously volunteered in mental health, social services, or a related area? Yes No
Agency: Department/Unit:
Job Title:
Volunteer Dates: From _____ / _____ / _______ To: _____ / _____ / _______
Agency: Department/Unit:
Job Title:
Volunteer Dates: From: _____ / _____ / _______ To: _____ / _____ / _______
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:
Email: Email:
I certify that all of the information provided here is true and accurate to the best of my knowledge.
___________________________________________________ ______/_____/______
