Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
January 18, Vol. 08-07

Center for Mental Health Services Consolidated Application Deadline: Postmarked by February 15, 2008

The Center for Mental Health Services (CMHS), within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with AFYA, Inc., is providing financial support to consumers of mental health services who would like to participate in the following annual meetings: 2008 SAMHSA/Centers for Medicare and Medicaid Services (CMS) Invitational Conference on Medicaid and Mental Health Services and Substance Abuse Treatment, National Association of Peer Specialists, National Association of Rural Mental Health, National Council for Community Behavioral Healthcare and/or the International Conference on Self-Determination. You can apply for no more than two conferences to be considered for scholarships; however, an individual may only receive a scholarship to one conference. For more information, check available web sites.

Please note: To be eligible for these scholarships, a completed application and letter of recommendation must be post marked by February 15, 2008.

Conference Selection: I would like to make application for the following conference(s): Please check no more than two. ______

National Council for Community Behavioral Healthcare May 1-3, 2008 Boston, MA http://www.thenationalcouncil.org/cs/boston  _______

The International Conference on Self-Determination May 27-29, 2008 Detroit, MI http://www.self-determination.com/  _______

National Association of Rural Mental Health August 6-9, 2008 Burlington, VT http://www.narmh.org/conferences/  _______

National Association of Peer Specialists August 20-22, 2008 Philadelphia, PA http://naops.org/  _______

2008 SAMHSA/CMS Invitational Conference on Medicaid and Mental Health Services and Substance Abuse Treatment September 23-24, 2008 Baltimore, MD  _______

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:

U.S. Citizen
_____ Yes _____ No

Gender
_____ Male _____ Female

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

Ethnicity
_____ American Indian
_____ Asian/Pacific Islander
_____ Black (not of Hispanic origin)
_____ Hispanic
_____ White (not of Hispanic origin)
_____ Other

Sexual Orientation
_____ Heterosexual
_____ Gay
_____ Lesbian
_____ Bisexual

Physical Disability
_____ 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 any of these conferences 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(s)?
2. Are you making a presentation at this conference(s)? If yes, please describe.
3. How will you disseminate information obtained at this conference(s) 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 these scholarships, 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 not later than Friday, March 14, 2007, to discuss 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 each 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 each conference.
3. Submit a travel reimbursement form to AFYA within 2 weeks of the conclusion of each 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, as soon as possible, if you are unable to attend the conference or will be delayed in meeting any of the above conditions.

I understand and accept the above requirements.

Signature _____________________________________

Date _________________________

Please submit your completed application and letter(s) of recommendation by U.S. Mail only to:

Jackee Williams, CMP
Senior Conference Manager
AFYA, Inc.
8101 Sandy Spring Road, Suite 301
Laurel, MD 20707
Phone: (301) 957-3040, Ext. 263

Please note that your completed application must be postmarked no later than February 15, 2008.

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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.