Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
March 14, 2007, Vol. 07-54

Alternatives 2007 Conference
"Spanning the Recovery Movement: Consumer Control and Choice"
October 10-14, 2007 in St. Louis, MO
Center for Mental Health Services Application for Financial Support
Application deadline: May 25, 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), are providing financial support to consumers of mental health services who wish to participate in the 2007 Alternatives Conference. The conference host is the Mental Health Association of Southeastern Pennsylvania, National Mental Health Consumers' Self-Help Clearinghouse. 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 U.S. Mail, postmarked on or before the deadline of May 25, 2007. NO FAX OR EMAIL SUBMISSIONS WILL BE ACCEPTED.

Conference information is available at www.alternatives2007.org or by calling (800) 776-1286.

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: __________________________________________

Alternate 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:

American Indian _____ Asian/Pacific Islander _____

Black (not of Hispanic origin) _____ Hispanic _____

White (not of Hispanic origin) _____

Other ________________________

Sexual Orientation:

Heterosexual _____ Gay _____

Lesbian _____ Bisexual _____

Special Needs Physical Disability: Yes _____ No _____

U.S. Citizen: Yes _____ No _____

Financial Support:

What type of scholarship support are you seeking? (please check one.)

Full _____ Partial (I have partial support from another sponsor.) _____

What type of funding are you seeking? (please check all that apply.)

Registration Fee _____ Hotel _____

Per Diem (daily allowance for meals and incidental expenses) _____ 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 in the past a scholarship from CMHS to attend this conference?

Yes _____ No _____

If yes, what year(s)? ______________

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

Yes _____ No _____

If yes, State what is the sponsor's name. ____________________________

For what year(s)? ______________

Logistics Information:

Do you have any special needs that would prohibit double occupancy?

Yes _____ No _____

If yes, please list any special needs. _____________________________________

Additional Information:

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

1. Why do 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 by June 22, 2007, to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit to AFYA, within 2 weeks of the conclusion of the conference, a 2-5 page report in a format that AFYA will provide. Your report will be summarized and shared with CMHS, other scholarship recipients, the sponsoring conference organization, and others.
2. Submit to AFYA, within 2 weeks of the conclusion of the conference, an evaluation in a format AFYA , Inc. will provide.
3. Submit to AFYA, within 2 weeks of the conclusion of the conference, a travel reimbursement form.
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 IMMEDIATELY if you are unable to attend the conference or if you will be delayed in meeting any of the above conditions.

Signature: ___________________________________________

Date: _______________________________________________

Please submit your completed application and letter(s) of recommendation BY US MAIL ONLY to:

Lethia A. Kelly, CMP, Senior Conference Manager
AFYA, Inc.
8101 Sandy Spring Road
Laurel, MD 20707
Phone: (301) 957-3040, Ext. 249
E-mail: lkelly@afyainc.com
Please note that your complete application must be postmarked on or before May 25, 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.