Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
March 21, 2007, Vol. 07-56

Depression and Bipolar Support Alliance (DBSA)
2007 Conference and Chapter Leadership Forum
"Making The Recovery Connection" - August 9-12, 2007
Buena Vista Palace Hotel and Spa - Orlando, FL

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), is providing financial support to consumers of mental health services who would like to participate in the annual conference sponsored by the Depression and Bipolar Support Alliance. 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 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.DBSAlliance.org or by calling (800) 826-3632.

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: __________________________________________

DBSA Chapter/Support Group Affiliation (if any) : __________________________________

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 all that apply)

Registration Fees _____ Hotel _____

Per diem (daily allowance for meals and incidental expenses) _____ Ground transportation _____

Travel costs (please choose one from below)

Airfare _____ Train _____

Car Mileage _____

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

Yes _____ No _____

If yes, what year(s)? ______________

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. Will you 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 DBSA programs and activities? If yes, please describe.

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 29, 2007, to discuss logistics arrangements. Scholarships cover registration fee, hotel expenses (based on double occupancy), ground transportation, per diem and airfare. In order to provide as many scholarships as possible, we ask that you share a room with another scholarship recipient.

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, DBSA, 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. Be asked to share a room with another person in order to provide as many scholarships as possible.
5. 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.
6. 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 BY US MAIL ONLY to:

Lethia A. Kelly, CMP
Senior Conference Manager
AFYA, Inc.
8101 Sandy Spring Road, Suite 301
Laurel, MD 20707
Phone: (301) 957-3040, Ext. 249 or (301) 957-3049 (Direct)
Fax: (301) 497-9902
E-mail: lkelly@afyainc.com or consumerscholarships@afyainc.com

Please note that in order to be considered for a scholarship, your complete application must be received by AFYA by U.S. Mail, postmarked on or before May 25, 2007. NO FAX OR EMAIL SUBMISSIONS WILL BE ACCEPTED.

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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.