Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
January 8, 2007, Vol. 07-04

MHA 2007 Annual Meeting
"Bringing Wellness Home"
June 6-9, 2007
Washington, DC

Center for Mental Health Services Application for Financial Support
Application deadline: March 30, 2007

The Center for Mental Health Services (CMHS), within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with AFYA, Inc. (AFYA), is providing financial support to consumers of mental health services who would like to participate in the annual conference sponsored by the Mental Health America, formerly the National Mental Health Association. The purpose of the scholarships is to foster transformation of mental health care to focus on recovery. Please note: To be eligible for this scholarship, a completed application and letter of recommendation must be received by March 30, 2007.

Conference information is available at: www.mentalhealthamerica.net

Please PRINT the following information as you would like it to appear on the participants list. PLEASE DO NOT USE ACRONYMS.

Contact Information:

Name: ___________________________________________

Title: ____________________________________________

Organization/Agency: _______________________________

Mailing Address: __________________________________

City: __________________ State: _______ Zip: _________

Telephone: (______) _______________________________

Fax: (______) ____________________________________

E-mail: __________________________________________

Emergency Contact Information:
In case of emergency, please contact:

Name: ___________________________________________

Relationship: ______________________________________

Organization/Agency: _______________________________

Address: __________________________________

City: __________________ State: _______ Zip: _________

Telephone: (______) _______________________________

Emergency Telephone: (______) ______________________

Demographic Information (optional):

Gender: Male _____ Female _____

Age: 18-25_____ 26-55 _____ 56+ _____

Ethnicity:

Asian/Pacific Islander _____ American Indian _____

Black (not of Hispanic origin) _____ Hispanic _____

White (not of Hispanic origin) _____

Other ________________________

Sexual Orientation:

Heterosexual _____ Gay _____

Lesbian _____ Bisexual _____

Physical Disability: Yes _____ No _____

U.S. Citizen: Yes _____ No _____

Financial Support:

What type of scholarship support are you seeking? (please check all that apply)

Registration Fee _____ Hotel _____

Per diem _____ Ground transportation _____

Travel costs (please choose one from below)

Airfare _____ Train _____

Car Mileage _____ (mileage is based on Federal Regulations - and must not exceed lowest airfare)

Have you received a scholarship from CMHS to attend this conference in the past?

Yes _____ No _____

If yes, what year(s)? ______________

Have you received a scholarship from another sponsor to attend this conference in the past?

Yes _____ No _____

If yes, State sponsor's name. What year(s)? ______________

Logistics Information:

Do you have any lodging limitations that would prohibit double occupancy?

Yes _____ No _____

If yes, state limitation. _____________________________________

Additional Information:

On a separate piece of paper, please provide the review committee with the following information:

1. What are the reasons you wish to attend the conference?
2. Are you making a presentation at this conference? If yes, please describe.
3. How will you disseminate information obtained at this conference to local or statewide consumer groups?
4. What are the specific issues relating to mental health in which you are most interested?
5. Are you currently involved with any related programs and activities? If yes, please describe.

Please provide at least one letter of recommendation with your completed application.

Scholarship Conditions:

Please note that to be eligible for this scholarship, you must be a U.S. citizen and a mental health consumer. If you are selected as a scholarship recipient, a representative from AFYA will contact you to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit to AFYA a 2 to 5 page report in a format provided within 2 weeks of the conclusion of the conference. Your report will be summarized and shared with CMHS, other scholarship recipients, the sponsoring conference organization, and others.
2. Submit to AFYA an evaluation in a format provided within 2 weeks of the conclusion of the conference.
3. Submit a travel reimbursement form to AFYA within 2 weeks of the conclusion of the conference.
4. Agree to have your name and contact information shared with other scholarship recipients. If you would like to keep your contact information confidential, please contact AFYA.
5. Inform AFYA if you are unable to attend the conference or will be delayed in meeting any of the above conditions.

Signature: ___________________________________________

Date: _______________________________________________

Please submit your completed application and letter(s) of recommendation to:

Lethia A. Kelly, CMP
Senior Conference Manager
AFYA, Inc.
8101 Sandy Spring Road, Suite 301 Laurel, MD 20707
Phone: (301) 957-3049 (Direct)
(301) 957-3040, Ext. 249
Fax: (301) 457-9902
E-mail: lkelly@afyainc.com
Please note that your complete application must be received by AFYA by March 30, 2007

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The Center for Mental Health Services is a component of the Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services.