Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
February 13, 2004, Vol. 04-15

Consumer Scholarships Available to American Psychiatric Assocation (APA) 2004 Annual Conference

When and Where:
May 1-6, 2004
New York, New York

Conference information available at: http://www.psych.org/edu/ann_mtgs/am/04/index.cfm

Application deadline: March 5, 2004

The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with Westat/Health Systems Research, Inc. (HSR), is providing financial support to consumers of mental health services who wish to participate in the annual conference sponsored by the American Psychiatric Association. Please note, the completed application and letter of must be received by March 5, 2004 in order to be eligible for this scholarship.

If interested in applying, please fill out the following application and forward to:

Stephanie Hauser
Health Systems Research, Inc.
1200 18th Street, NW, Suite 700
Washington, DC 20036
Phone: (202) 828-5100
Fax: (202) 728-9469
E-mail: shauser@hsrnet.com
Pager: (800) 619-4175 (Please leave your phone number including area code and we will return your call as soon as possible.)

You may also use this contact information if you have any questions or would like a hard copy version of this application.

SCHOLARSHIP APPLICATION FORM

Contact Information:

NAME:
ORGANIZATION:
ADDRESS:
CITY: STATE: ZIP:
PHONE:
FAX:
E-MAIL:

Demographic Information:

Please provide the following optional information to help insure diversity of scholarship recipients. This section is voluntary and choosing not to complete it will not effect the evaluation of your application.

Gender:
____ Male
____ Female

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

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

Sexual Orientation:
____ Heterosexual
____ Gay
____ Lesbian
____ Bisexual

Physical Disability:
____ Yes
____ No

Are you a U.S. citizen?
____ Yes
____ No

Financial Support: What type of scholarship support are you seeking (please check all that apply)?
____ Registration fee
____ Hotel expense
____ Per diem
____ Ground transportation

Travel costs (please choose one from below):
____ airfare
____ train
____ mileage for car

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. How you will disseminate information obtained at this conference to local or statewide consumer groups?
3. What are the specific issues relating to mental health in which you are most interested?
4. 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 in order 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 of HSR will contact you by April 9, 2004 to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit a 2 to 5 page report to HSR within 2 weeks of the conclusion of the conference in a format provided by HSR.
2. Submit an evaluation to HSR within 2 weeks of the conclusion of the conference.
3. Submit a travel reimbursement form to HSR within 2 weeks of the conclusion of the conference.
4. Inform the HSR if you are unable to attend the conference or will be delayed in meeting the other three conditions.

Your signature below indicates that you have read and agree with the terms above.

Signature:

Date:

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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.